New doctors are turning the tables on seasoned physician leaders by introducing strategies to improve quality by curtailing opportunities for medical error and harm. They're also saving hospitals millions in unnecessary spending.
This article appears in the January/February 2014 issue of HealthLeaders magazine.
A decade ago, young doctors fresh out of residency would loyally follow their senior mentors, diligently emulate their sage practices, and rarely second-guess. That's just the way it was in medical training.
But in a dozen or so hospitals—from San Francisco to San Jose and Boston to Baltimore—the tables are turning on the senior physician guard.
On these wards today, it's upstart youngsters now teaching their seasoned attendings and physician leaders about a new world order of hospital medicine—one that improves quality while it reduces waste, inappropriate care, and often, the opportunity for medical error and harm.
And by the way, these new doctors say, their strategies also avoid millions in unnecessary spending: a few tens of thousands here, a few tens of thousands there. It's adding up to real money, and that has brought smiles to the C-suite.
Reexamining appropriate utilization
Physicians for Responsible Ordering is one such effort started by residents and faculty at the approximately 565-bed Johns Hopkins Bayview Medical Center in Baltimore who created the group in 2010 and raised questions about several routine practices; the new protocols they launched have eliminated some interventions, with no evidence of patient harm.
Now, when the subject of PRO comes up among senior physicians, Bayview's Executive Vice President and Chief Operating Officer Charles Reuland says, "My faculty leaders and I jokingly recite this quote attributed to Gandhi, 'There goes my people. I must follow them, for I am their leader.' "
"We love it that they're doing this because they're putting us on the right course," Reuland says. "The fact is, it's many of our trainees and younger physicians who are helping us control utilization and cost."
These aren't big ticket items, like the purchase of an expensive robot. But these thirtysomething clinicians are digging into the weeds of routine hospital processes and scrutinizing order sets, eliminating tests or imaging that almost never change a diagnosis but instead often prompt further testing and invasive procedures that needlessly waste resources.
Questioning routine practices
They're avoiding medical errors by switching patients from higher-risk intravenous medications to safer and less resource-intense oral doses.
They're "questioning the practice of daily lab ordering in all hospitalized patients, many of whom are already in a weakened state. These efforts may reduce hospital-acquired anemia," according to 36-year-old PRO lead organizer Anthony Accurso, MD. The group seeks to organize physicians in the hospital who share an interest in high-value care and agree to question the utility of these daily practices.
Twenty years ago, Reuland says, "we thought that if we as providers had an intervention that could possibly help someone, then giving patients access to it was a good thing. I think a generation later, we're learning that turning off our medical apparatus is as important sometimes as turning it on."
Saving money and avoiding harm
One such project to pare costs and avoid harm is the brainchild of Jeffrey Trost, MD, 43, director of Bayview's cardiac catheterization laboratory and deputy director for clinical practice.
Trost made a persuasive case to almost completely eliminate redundant and less accurate cardiac enzyme blood draws—tests that added costs to hospital expenses and patients' bills—when the troponin enzyme test did a much better job at detecting blockage of blood supply to heart muscle.
Trost says as he was starting out in the cath lab, he'd see people referred for procedures who'd had "double-digit" quantities of creatine kinase (CK) or creatine kinase–myocardial band (CK-MB) cardiac enzyme blood tests, when two or three would have sufficed.
"It struck me as wasteful and wrong," he says. "Imagine if you as a patient knew that your doctor ordered 10 or 11 tests when two or three would do—and either you or your insurance company is going to pay for it; we all wind up paying for it somehow."
So many blood draws can cause harm, he says. "In theory and in practice, by reducing the number of cardiac tests ordered, we reduced potential harm by reducing unnecessary blood draws and, more important, reduced the number of downstream tests, such as stress tests and invasive cardiac procedures that would be prompted by abnormal results."
With support from leadership, Trost and colleagues created and distributed an evidence-based guideline with "suggestions" physicians could use when ordering these tests.
Over the next 12 months, they found a 66% reduction in cardiac enzyme tests compared with the prior 30 months, and no missed diagnoses.
Although actual cost-reduction estimates are difficult because of Maryland's unique prospective payment system, hospital charges to payers dropped by $1.2 million, Trost says.
Oral versus intravenous drugs
Across the country at 722-bed University of California San Francisco Medical Center, hospitalist Christopher Moriates, MD, just one year out of residency, has launched the High Value Care Committee and has reduced spending and potential harm in at least six ways.
Josh Adler, MD, UCSF chief medical officer, says one such project directs clinicians to move patients from intravenous administration of about 20 drugs to less expensive oral doses whenever possible. Oral dosages lower the risk of infection, decrease potential injury to the vein that can lead to phlebitis, and reduce the severity of any medical error that may occur because IVs deliver drugs to the bloodstream much faster than oral doses.
"Cost is also a factor, because it's much more expensive to give an IV drug than an oral one, much easier on the nurse in terms of workflow and efficiency," he says. "If a nurse no longer has to give total attention to programming an IV drug, that means he or she has more time to concentrate on other important aspects of that patient's care, or maybe just listen to the patient or help them to the bathroom, those other activities that are compromised when nurses are doing other activities."
Adler says UCSF has made thousands of drug switches, and is in the process of analyzing data to estimate cost savings, which he says "could be in the hundreds of thousands of dollars" per year.
Ending unnecessary care
Moriates' High Value Care Committee has prompted efforts that Adler says have placed UCSF "somewhat on the forefront of systematically rooting out unnecessary care in ways that are less dangerous and less expensive. We're committing ourselves to change the status quo with a campaign to create the educational and moral imperative that we need to do this."
Among other UCSF efforts are these:
Nebs No More After 24. A cost saving of $250,000 on one floor of the hospital—and perhaps $1 million a year hospitalwide—is realized by having patients with obstructive pulmonary disease stop using nebulizers, which requires presence of a respiratory therapist. Instead, after 24 hours on nebulizers, the patients are trained to properly use inhalers while still in the hospital.
The $20 iCal test. Educational efforts and a change in the computerized physician order entry system have reduced the use of this test from 3,660 per month to 1,300, an estimated annual savings of $150,000 after one year. False or vague results can prompt intravenous administration of calcium, which can cause several adverse reactions, such as arrhythmia.
Transfusions. Providers are reducing the number of transfusions. When transfusions are required, fewer units may be given because of research in the past decade showing that transfusing too many units to maintain higher hemoglobin levels is unnecessary, and could result in worse patient outcomes.
Elimination of routine testing. Hospital staff ask physicians to individually order blood tests only when they're needed, instead of ordering all 20 in an order set. Early estimates are that these efforts have reduced overall lab testing by 6%.
Adler acknowledges that making many of these changes wasn't easy. Pushback from senior physicians had to be overcome. "They'd say things like, 'I believe IV administration is better.' But in many cases we showed compelling scientific evidence that it wasn't. And that proved pretty convincing."
Financial harm and patient harm
In Boston, one of the leaders of this physician cost and quality movement is Neel Shah, MD, 31, executive director of Costs of Care, a project he started in 2009 as he began his obstetrics residency at Brigham & Women's Hospital.
He did so when, during his OB rotation, "I couldn't understand why people were opening up a pair of gloves to do an exam, but only using one glove and throwing the other away," he says. "Then I found out that each glove was $5." He also saw different surgeons using different pieces of equipment for the same procedure, one costing $300 and the other $5,000, with no evidence the $5,000 one was better or necessary.
The idea behind Costs of Care, he says, was to gather similar stories from clinicians around the country about waste, high cost, and overuse. An underlying premise, he emphasizes, is that "financial harm is a very real form of patient harm, a basic quality issue," because it meant, for some people, choosing treatment might land them in bankruptcy or cause stress that exacerbates their underlying illness.
At first, he acknowledges, his ideas weren't very popular with his superiors.
"As a junior person, it was very hard not to be perceived as a whippersnapper when you're talking about how to make healthcare better. And there's extra sensitivity at an academic medical center where care is even more expensive" than at community hospitals.
But timing was everything: The start of the Obama administration and its healthcare focus, and the Costs of Care website and the story submissions from physicians and some patients exploded, giving Shah and the organization a national profile. "It was the first time we had a large cohort of physicians to step up and say, 'This is what we see every day.' "
Shah emphasizes that while cost is not something usually perceived as a quality issue, "it absolutely is one." For example, one of his projects is to reduce unnecessary C-sections.
Now at Beth Israel Deaconess Medical Center, Shah is working on an ambitious project with the hospital's finance office to determine the true costs of labor and delivery, dissecting each piece of that care pathway from patient check-in to discharge, asking who does what job and how long it takes. The goal is to reorganize the process to minimize its cost and improve quality.
Avoiding harm and pain
South of San Francisco, Alan Schroeder, MD, chief of pediatric inpatient services at 327-bed Santa Clara Valley Medical Center in San Jose, and colleagues are working on eliminating care for children that's unnecessary, costly, and sometimes actually causes harm and pain.
Three years ago, they looked at the common pediatric practice of performing routine imaging on children under age 2 with a urinary tract infection and fever. The protocol at most hospitals involved a care pathway that included a painful, often traumatic follow-up catheterization procedure called a voiding cystourethrogram to detect potential problems in the child's kidney.
That procedure costs about $2,000 and exposes infants to unnecessary radiation and prophylactic use of antibiotics, with no benefit to their course of care, Schroeder says.
"As physicians, we're not that connected with cost, so doctors often just shrug it off," Schroeder notes. "But when you start to see that these unnecessary tests are harming the patient by exposing them to radiation, pain, or positive tests that are of questionable significance, leading to further testing and treatment based on an original test that shouldn't have been done in the first place, that's the huge issue that keeps coming up."
At Johns Hopkins, Reuland notes that times are changing, and senior leaders need to think about the process of providing care in much different ways, because the definition of doing the right thing is changing rapidly.
"In the past 10 years, it's my observation that our medical training program has certainly focused more on teaching our physicians and residents that utilization management is important," which wasn't so much the case in generations before.
Now, he says, "it's about a hospital's long-term sustainability. If you're an organization that's not perceived as doing the right thing, that's a sustainability problem in and of itself."
Reprint HLR0214-11
This article appears in the January/February 2014 issue of HealthLeaders magazine.