Effect of statewide reduction in extended care facility use after joint replacement on hospital readmission.

BACKGROUND: Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments. METHODS: We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012-2013) and after (2016-2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests. RESULTS: Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P < .0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P < .0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to -16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use. CONCLUSION: Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement.

Development, Implementation, and Evaluation of a Telemedicine Preoperative Evaluation Initiative at a Major Academic Medical Center.

BACKGROUND: With health care practice consolidation, the increasing geographic scope of health care systems, and the advancement of mobile telecommunications, there is increasing interest in telemedicine-based health care consultations. Anesthesiology has had experience with telemedicine consultation for preoperative evaluation since 2004, but the majority of studies have been conducted in rural settings. There is a paucity of literature of use in metropolitan areas. In this article, we describe the implementation of a telemedicine-based anesthesia preoperative evaluation and report the program's patient satisfaction, clinical case cancellation rate outcomes, and cost savings in a large metropolitan area (Los Angeles, CA). METHODS: This is a descriptive study of a telemedicine-based preoperative anesthesia evaluation process in an academic medical center within a large metropolitan area. In a 2-year period, we evaluated 419 patients scheduled for surgery by telemedicine and 1785 patients who were evaluated in-person. RESULTS: Day-of-surgery case cancellations were 2.95% and 3.23% in the telemedicine and the in-person cohort, respectively. Telemedicine patients avoided a median round trip driving distance of 63 miles (Q1 24; Q3 119) and a median time saved of 137 (Q1 95; Q3 195) and 130 (Q1 91; Q3 237) minutes during morning and afternoon traffic conditions, respectively. Patients experienced time-based savings, particularly from traveling across a metropolitan area, which amounted to $67 of direct and opportunity cost savings. From patient satisfaction surveys, 98% (129 patients out of 131 completed surveys) of patients who were consulted via telemedicine were satisfied with their experience. CONCLUSIONS: This study demonstrates the implementation of a telemedicine-based preoperative anesthesia evaluation from an academic medical center in a metropolitan area with high patient satisfaction, cost savings, and without increase in day-of-procedure case cancellations.

Quality assessment and cost saving of renal dosing recommendation by clinical pharmacists at medical wards in Thailand.

Background Renal dosage adjustment for patients with reduced kidney function is a common function of clinical pharmacy service. Assessment of pharmacist's intervention in the aspect of quality and economic impact should be conducted to evaluate the benefit of this service. Objective This study aimed to assess the quality and cost saving of clinical pharmacists' recommendation on renal dosage adjustment among patients with reduced kidney function. Setting Eight medical wards of the Siriraj Hospital, a tertiary-care hospital in Bangkok, Thailand. Method A retrospective study was conducted using medical records and clinical pharmacist's intervention database. All patients admitted to the study wards whose estimated creatinine clearance were less than 60 mL/min or presented with acute kidney injury on admission during October 2016-December 2017 were included. The targeted medications were antimicrobial agents. Main outcome measure Percentage of the concordance between pharmacists' recommendation compared to standard dosing references and related cost saving. Results Among 158 patients, pharmacists provided 190 recommendations, including 151 (79.1%) dose reduction, 17 (8.9%) dose increase and 22 (11.5%) recommendations to provide supplemental dose after dialysis. These recommendations were 90.5% consistent with standard references. Physician accepted and complied with 89.5% of pharmacists' recommendations. Average direct cost saving was €5,114.11 while cost avoidance was €863.47. Conclusion Trained clinical pharmacists were able to provide high-quality recommendation on dosage adjustment in these patients in accordance to standard dosing guidelines. In addition, dosage adjustment also led to a significant direct cost saving and cost avoidance from prevention of adverse drug reactions.

Physician Perceptions of Step Therapy Prescribing Requirements.

BACKGROUND: Step therapy policies that require prescribers to follow an ordered protocol for drug choices are widely used by public and private insurers to manage medication costs; however, the perceptions of prescribing physicians regarding these policies have not been studied. OBJECTIVE: To determine physician attitudes toward step therapy policies and the correlation of these beliefs with physician characteristics. METHODS: A sample of clinically active physicians specializing in internal medicine, cardiology, or endocrinology received a survey administered online or via mail. Five-point Likert scale questions assessed physicians' opinions of clinical, economic, and implementation elements of prior authorization policies; physician demographic characteristics; and the extent of their interactions with the pharmaceutical industry. RESULTS: 686 physicians (48%) responded to the survey, which was evenly divided among primary care physicians, endocrinologists, and cardiologists. Many respondents (70%) had interactions with industry, including receipt of meals or gifts and use of medication samples. Physicians reported that step therapy policies could improve the affordability of medication use (55% agree vs. 26% disagree) and its clinical appropriateness (59% agree vs. 19% disagree). By similar margins, however, physicians stated that step therapy policies were implemented inefficiently and inflexibly and often did not incorporate relevant patient-specific information. Physicians in subspecialties, especially endocrinology, and those who had interactions with the pharmaceutical industry were more likely to hold negative views of step therapy policies. CONCLUSIONS: Most physicians recognize the potential of step therapy to improve the quality and cost-effectiveness of prescribing, although interactions with industry may affect these opinions. Physician perception of ineffective implementation of these policies, however, undermines their acceptability. DISCLOSURES: The American Board of Internal Medicine (ABIM) funded the survey used in this study. The ABIM had no role in the design and conduct of the study or development and preparation of the manuscript. Survey honoraria was provided by the Consumers Union. Kesselheim and Avorn's work is funded by the Laura and John Arnold Foundation. Kesselheim is also supported by the Harvard-MIT Center for Regulatory Science, Arnold Ventures, and the Engelberg Foundation. Ross is employed by the ABIM. Fischer, Lu, and Tessema have nothing to disclose.

Optimizing the Role of Community Pharmacists in Managing the Health of Populations: Barriers, Facilitators, and Policy Recommendations.

The shift to a value-based health care system has incentivized providers to implement strategies that improve population health outcomes while minimizing downstream costs. Given their accessibility and expanded clinical care models, community pharmacists are well positioned to join interdisciplinary care teams to advance efforts in effectively managing the health of populations. In this Viewpoints article, we discuss the expanded role of community pharmacists and potential barriers limiting the uptake of these services. We then explore strategies to integrate, leverage, and sustain these services in a value-based economy. Although community pharmacists have great potential to improve population health outcomes because of their accessibility and clinical interventions that have demonstrated improved outcomes, pharmacists are not recognized as merit-based incentive eligible providers and, as a result, may be underutilized in this role. Additional barriers include lack of formal billing codes, which limits patient access to services such as hormonal contraception; fragmentation of Medicare, which prevents alignment of medical and pharmaceutical costs; and continued fee-for-service payment models, which do not incentivize quality. Despite these barriers, there are several opportunities for continued pharmacist involvement in new care models such as patient-centered medical homes (PCMH), accountable care organizations, and other value-based payment models. Community pharmacists integrated within PCMHs have demonstrated improved hemoglobin A1c, blood pressure control, and immunization rates. Likewise, other integrated, value-based models that used community pharmacists to provide medication therapy management services have reported a positive return on investment in overall health care costs. To uphold these efforts and effectively leverage community pharmacist services, we recommend the following: (a) recognition of pharmacists as providers to facilitate full participation in performance-based models, (b) increased integration of pharmacists in emerging delivery and payment models with rapid cycle testing to further clarify the role and value of pharmacists, and (c) enhanced collaborative relationships between pharmacists and other providers to improve interdisciplinary care. DISCLOSURES: This article was funded by the National Association of Chain Drug Stores. The authors have no potential conflicts of interest to report.

[A pragmatic approach to managing expensive therapies]. / Une approche pragmatique pour gérer les traitements onéreux - Chroniques génomiques.

Inflated drug prices necessarily raise the issue of rational allocation of health care resources. The system operated by the NICE agency in the UK attempts to do this by calculating the cost per quality-adjusted life year gained (QALY) and recommending funding only for drugs whose cost per QALY falls under a certain threshold. The whole process is documented in detail and easily accessible, and often results in significant discounts on drug prices. Given that some kind of rationing of health care is inevitable, the rational and transparent process followed by NICE has a number of positive features.

Supply chain optimization at an academic medical center.

PURPOSE: A successful supply chain optimization project that leveraged technology, engineering principles, and a technician workflow redesign in the setting of a growing health system is described. SUMMARY: With continued rises in medication costs, medication inventory management is increasingly important. Proper management of central pharmacy inventory and floor-stock inventory in automated dispensing cabinets (ADCs) can be challenging. In an effort to improve control of inventory costs in the central pharmacy of a large academic medical center, the pharmacy department implemented a supply chain optimization project in collaboration with the medical center's inhouse team of experts on process improvement and industrial engineering. The project had 2 main components: (1) upgrading and reconfiguring carousel technology within an expanded central pharmacy footprint to generate accurate floor-stock inventory replenishment reports, which resulted in efficiencies within the medication-use system, and (2) implementing a technician workflow redesign and algorithm to right-size the ADC inventory, which decreased inventory stockouts (i.e., incidents of depletion of medication stock) and improved ADC user satisfaction. CONCLUSION: Through a multifaceted approach to inventory management, the number of stockouts per month was decreased and ADC inventory was optimized, resulting in a one-time inventory cost savings of $220,500.

Single Institution Early Experience with the Bundled Payments for Care Improvement Initiative.

The Centers for Medicare & Medicaid Services (CMS) implemented the Bundled Payments for Care Improvement (BPCI) initiative in 2011. Through BPCI, organizations enlisted into payment agreements that include both performance and financial accountability for episodes of care. To succeed, BPCI requires quality maintenance and care delivery at lower costs. This necessitates physicians and hospitals to merge interests. Orthopaedic surgeons must assume leadership roles in cost containment, surgical safety, and quality assurance to deliver cost-effective care. Because most orthopaedic surgeons practice independently and are not employed by hospitals, models of physician-hospital alignment (e.g., physician-hospital organizations) or contracted gainsharing arrangements between practices and hospitals may be necessary for successful bundled pricing. Under BPCI, hospitals, surgeons, or third parties share rewards but assume risks for the bundle.For patients, cost savings must be associated with maintenance or improvement in quality metrics. However, the definition of quality can vary, as can the rewards for processes and outcomes. Risk stratification for potential complications should be considered in bundled pricing agreements to prevent the exclusion of patients with substantial comorbidities and higher care costs (e.g., hip fractures treated with prostheses). Bundled pricing depends on economies of scale for success; smaller institutions must be cautious, as 1 costly patient could substantially impact the finances of its entire program. CMS recommends a minimum of 100 to 200 cases yearly. We also suggest that participants utilize technologies to maximize efficiency and provide the best possible environment for implementation of bundled payments. Substantial investment in infrastructure is required to develop programs to improve coordination of care, manage quality data, and distribute payments. Smaller institutions may have difficulty devoting resources to these infrastructural changes, although changes may be implemented more thoroughly once initiated. Herein, we discuss our early total joint arthroplasty BPCI experience at our tertiary-care academic medical center.

Performance of a Condensed Protocol That Reduces Effort and Cost of NIA-AA Guidelines for Neuropathologic Assessment of Alzheimer Disease.

Concerns regarding resource expenditures have been expressed about the 2012 NIA-AA Sponsored Guidelines for neuropathologic assessment of Alzheimer disease (AD) and related dementias. Here, we investigated a cost-reducing Condensed Protocol and its effectiveness in maintaining the diagnostic performance of Guidelines in assessing AD, Lewy body disease (LBD), microvascular brain injury, hippocampal sclerosis (HS), and congophilic amyloid angiopathy (CAA). The Condensed Protocol consolidates the same 20 regions into 5 tissue cassettes at ∼75% lower cost. A 28 autopsy brain-retrospective cohort was selected for varying levels of neuropathologic features in the Guidelines (Original Protocol), as well as an 18 consecutive autopsy brain prospective cohort. Three neuropathologists at 2 sites performed blinded evaluations of these cases. Lesion specificity was similar between Original and Condensed Protocols. Sensitivities for AD neuropathologic change, LBD, HS, and CAA were not substantially impacted by the Condensed Protocol, whereas sensitivity for microvascular lesions (MVLs) was decreased. Specificity for CAA was decreased using the Condensed Protocol when compared with the Original Protocol. Our results show that the Condensed Protocol is a viable alternative to the NIA-AA guidelines for AD neuropathologic change, LBD, and HS, but not MVLs or CAA, and may be a practical alternative in some practice settings.

Determinants of success in Shared Savings Programs: An analysis of ACO and market characteristics.

BACKGROUND: Medicare's Accountable Care Organization (ACO) programs introduced shared savings to traditional Medicare, which allow providers who reduce health care costs for their patients to retain a percentage of the savings they generate. OBJECTIVE: To examine ACO and market factors associated with superior financial performance in Medicare ACO programs. METHODS: We obtained financial performance data from the Centers for Medicare and Medicaid Services (CMS); we derived market-level characteristics from Medicare claims; and we collected ACO characteristics from the National Survey of ACOs for 215 ACOs. We examined the association between ACO financial performance and ACO provider composition, leadership structure, beneficiary characteristics, risk bearing experience, quality and process improvement capabilities, physician performance management, market competition, CMS-assigned financial benchmark, and ACO contract start date. We examined two outcomes from Medicare ACOs' first performance year: savings per Medicare beneficiary and earning shared savings payments (a dichotomous variable). RESULTS: When modeling the ACO ability to save and earn shared savings payments, we estimated positive regression coefficients for a greater proportion of primary care providers in the ACO, more practicing physicians on the governing board, physician leadership, active engagement in reducing hospital re-admissions, a greater proportion of disabled Medicare beneficiaries assigned to the ACO, financial incentives offered to physicians, a larger financial benchmark, and greater ACO market penetration. No characteristic of organizational structure was significantly associated with both outcomes of savings per beneficiary and likelihood of achieving shared savings. ACO prior experience with risk-bearing contracts was positively correlated with savings and significantly increased the likelihood of receiving shared savings payments. CONCLUSIONS: In the first year, performance is quite heterogeneous, yet organizational structure does not consistently predict performance. Organizations with large financial benchmarks at baseline have greater opportunities to achieve savings. Findings on prior risk bearing suggest that ACOs learn over time under risk-bearing contracts. IMPLICATIONS: Given the lack of predictive power for organizational characteristics, CMS should continue to encourage diversity in organizational structures for ACO participants, and provide alternative funding and risk bearing mechanisms to continue to allow a diverse group of organizations to participate. LEVEL OF EVIDENCE: III.

Systematic Review of the Application of Lean and Six Sigma Quality Improvement Methodologies in Radiology.

PURPOSE: Preventable yet clinically significant rates of medical error remain systemic, while health care spending is at a historic high. Industry-based quality improvement (QI) methodologies show potential for utility in health care and radiology because they use an empirical approach to reduce variability and improve workflow. The aim of this review was to systematically assess the literature with regard to the use and efficacy of Lean and Six Sigma (the most popular of the industrial QI methodologies) within radiology. METHODS: MEDLINE, the Allied & Complementary Medicine Database, Embase Classic + Embase, Health and Psychosocial Instruments, and the Ovid HealthStar database, alongside the Cochrane Library databases, were searched on June 2015. Empirical studies in peer-reviewed journals were included if they assessed the use of Lean, Six Sigma, or Lean Six Sigma with regard to their ability to improve a variety of quality metrics in a radiology-centered clinical setting. RESULTS: Of the 278 articles returned, 23 studies were suitable for inclusion. Of these, 10 assessed Six Sigma, 7 assessed Lean, and 6 assessed Lean Six Sigma. The diverse range of measured outcomes can be organized into 7 common aims: cost savings, reducing appointment wait time, reducing in-department wait time, increasing patient volume, reducing cycle time, reducing defects, and increasing staff and patient safety and satisfaction. All of the included studies demonstrated improvements across a variety of outcomes. However, there were high rates of systematic bias and imprecision as per the Grading of Recommendations Assessment, Development and Evaluation guidelines. CONCLUSIONS: Lean and Six Sigma QI methodologies have the potential to reduce error and costs and improve quality within radiology. However, there is a pressing need to conduct high-quality studies in order to realize the true potential of these QI methodologies in health care and radiology. Recommendations on how to improve the quality of the literature are proposed.

[Quality Management in Medicine: What the Surgeon Needs to Know]. / Qualitätsmanagement in der Medizin. Was muss der Chirurg wissen?

Quality management (QM) is a method used in the field of economics that was adopted late by the medical sector. The coincidence of quality management and what is referred to as economisation in medicine frequently leads to QM being - incorrectly - perceived as part of the economisation problem rather than as part of its solution. Quality assurance defines and observes key performance indicators for the achievement of quality objectives. QM is a form of active management that intends to systematically exclude the effects of chance. It is supposed to enable those in charge of an institution to deal with complex processes, to influence them and achieve quality even under unfavourable circumstances. Clearly defined written standards are an important aspect of QM and allow for 80 % of patients to be treated faster and less labour-intensively and thus to create more capacity for the individual treatment of the 20 % of patients requiring other than routine care. Standards provide a framework to rely on for department heads and other staff alike. They reduce complexity, support processes in stress situations and prevent inconsistent decisions in the course of treatment. Document management ensures transparent and up-to-date in-house standards and creates continuity. Good documents are short, easy to use, and, at the same time, comply with requirements. Specifications describe in-house standards; validation documents provide a forensically sound documentation. Quality management has a broad impact on an institution. It helps staff reflect on their daily work, and it initiates a reporting and auditing system as well as the systematic management of responses to surveys and complaints. Risk management is another aspect of QM; it provides structures to identify, analyse, assess and modify risks and subject them to risk controlling. Quality management is not necessarily associated with certification. However, if certification is intended, it serves to define requirements, increase motivation for the implementation of measures to be taken, and provide long-term continuity in newly adopted processes. Specialist certificates issued by medical associations frequently emphasise an interdisciplinary treatment approach; however, their certification processes are often of poor quality. The effectiveness and efficiency is evident for individual QM instruments in medicine. It is very likely that quality management improves effectiveness in the whole field of medicine, but this has yet to be proved.

Implementation of Pharmaceutical Practice Guidelines by a Project Model Based: Clinical and Economic Impact.

All around the world a few studies have been found on the effect of guideline implementation on direct medications' expenditure. The goal of this study was to evaluate cost savings of guideline implementation among patients who had to receive 3 costly medications including albumin, enoxaparin, and pantoprazole in a tertiary hospital in Shiraz, Iran.An 8-month prospective study was performed in 2 groups; group 1 as an observational group (control group) in 4 months from June to September 2014 and group 2 as an interventional group from October 2014 to January 2015.For group 1 the pattern of costly medications usage was determined without any intervention. For group 2, after guideline implementation, the economic impact was evaluated by making comparisons between the data achieved from the 2 groups.A total of 12,680 patients were evaluated during this study (6470 in group 1; 6210 in group 2). The reduction in the total value of costly administered drugs was 56% after guideline implementation. Such reduction in inappropriate prescribing accounts for the saving of 85,625 United States dollars (USD) monthly and estimated 1,027,500 USD annually.Guideline implementation could improve the adherence of evidence-based drug utilization and resulted in significant cost savings in a major teaching medical center via a decrease in inappropriate prescribing of costly medications.

Making process improvement 'stick'.

To sustain gains from a process improvement initiative, healthcare organizations should: Explain to staff why a process improvement initiative is needed. Encourage leaders within the organization to champion the process improvement, and tie their evaluations to its outcomes. Ensure that both leaders and employees have the skills to help sustain the sought-after process improvements.

Reducing the blood culture contamination rate in a pediatric emergency department and subsequent cost savings.

BACKGROUND AND OBJECTIVE: Blood culture contamination in the pediatric population remains a significant quality and safety issue because false-positive blood cultures lead to unnecessary use of resources and testing. In addition, few studies describe interventions to reduce peripheral blood culture contamination rates in this population. We hypothesized that the introduction of a standardized sterile collection process would reduce the pediatric emergency department's peripheral blood culture contamination rate and unnecessary use of resources. METHODS: A sterile blood culture collection process was designed by analyzing current practice and identifying areas in which sterile technique could be introduced. To spread the new technique, a web-based educational model was developed and disseminated. Subsequently, all nursing staff members were expected to perform peripheral blood cultures by using the modified sterile technique. RESULTS: The peripheral blood culture contamination rate was reduced from 3.9% during the baseline period to 1.6% during the intervention period (P < .0001), with yearly estimated savings of ~$250,000 in hospital charges. CONCLUSIONS: Subsequent to our intervention, there was a significant reduction of the peripheral blood culture contamination rate as well as considerable cost savings to the institution. When performed in a standardized fashion by using sterile technique, blood culture collection with low contamination rates can be performed via the insertion of an intravenous catheter.