Where: University of California, San Francisco, a 600-bed academic medical center.
The issue: Reducing tests and interventions that increase costs without providing benefit.
Internal medicine residents at the University of California, San Francisco (UCSF), had been studying the issue of increasing health care value and reducing waste for years. But when Christopher Moriates, MD, transitioned from being a resident to an attending, hospital medicine director Robert Wachter, MD, FACP, encouraged him to take action on the issue.
“You're talking about cost, but you need to do something about it. Education is not going to move the needle,” described Dr. Moriates. So, in March 2012, Dr. Moriates and some colleagues, including hospitalists, residents, pharmacists, and administrators, formed a team focused on increasing the value of care provided by the medicine service.
How it works
The High-Value Care (HVC) program targets specific aspects of care that appear to incur significant costs without improving health outcomes. Its first project was the use of nebulized bronchodilator therapies for non-intensive care unit patients.
“That was kind of our flagship project,” said Dr. Moriates. “We put posters up in the hospital, we recruited residents.” The campaign tagline was “Nebs no more after 24!” to encourage clinicians to give patients metered-dose inhalers whenever possible, especially after 24 hours in the hospital. In addition to a publicity campaign, the initiative organizers removed nebulizers from the admission order set and enlisted respiratory therapists and nurses in the effort.
Other HVC projects quickly followed, along the same model. “We added these projects on, more or less one at a time. A hospital medicine fellow or a young faculty member would come and say, ‘Hey, I have this idea’ or ‘I want to look at this target,’” said Dr. Moriates. The next 5 projects were reducing overuse of stress ulcer prophylaxis, reducing blood transfusions in patients with hemoglobin >8.0 g/dL, keeping fewer patients on telemetry until discharge, ordering fewer ionized calcium tests, and not repeating echocardiograms on inpatients.
The first project succeeded in decreasing nebulizer use more than 50% within 6 months, according to results the team published in the Sept. 23, 2013, JAMA Internal Medicine and online July 1, 2014, in the Journal of Hospital Medicine.
“We report the nebs because we have the most data and experience with it, but we have very impressive and encouraging data for reducing our transfusions, also the stress ulcer prophylaxis, the telemetry reduction,” said Dr. Moriates. “We plan to report each of these out as we get the full data results.”
Under fee-for-service reimbursement, these reductions in unnecessary costs don't necessarily help a hospital's bottom line. That wasn't a major obstacle for the UCSF team because, as Dr. Moriates put it, “San Francisco is not the real world. We have a fairly progressive group here.” However, even with the support of administrators who were willing to lose short-term revenue for long-term improvements in efficient care, the HVC project has faced some challenges expanding beyond the hospital medicine service.
“We haven't addressed radiology in our program very much yet,” said Dr. Moriates. “When my division did a pilot project a few years ago looking at reducing radiology, there was a bit of pushback, with radiology saying, ‘Wait a second, we get paid for reading these tests.’ Outside of our department, people may see this a little differently.”
The HVC project continues to investigate new potential targets, while also making sure that the improvements already made are sustainable after the initial publicity campaigns have died down. “We're working on embedding systemic changes in this as well—working with our electronic medical record and changing how the orders are written,” said Dr. Moriates. “We think that we're changing the way that the physicians practice...the way they think about nebulizers and transfusions.”
He also hopes the program will serve as a model for other hospitals, although he warns that each hospital needs to come up with “locally meaningful” targets of their own. For example, reducing nebulizer use reduced costs at UCSF but wouldn't at every hospital. “That actually is very dependent on the idiosyncrasies of how your health care system delivers meds, how they pay for respiratory therapists' time,” Dr. Moriates said. “Engage the people on the ground who know where the problems are within your own system.”