Using Quality Improvement Methodology to Reduce Costs while Improving Efficiency and Provider Satisfaction in a Busy, Academic Musculoskeletal Radiology Division.

Within an everchanging healthcare system, continuous evaluation of standard operating procedures must be performed to ensure optimization of system level organization, communication, and efficiency. Using the Lean management approach, our institution introduced modifications to our musculoskeletal (MSK) radiology workflow in order to facilitate beneficial change that improved clinical workflow efficiency, reduced moonlighting costs, and improved radiologist satisfaction without sacrificing quality of care. The scope of our study included the MSK division of adult inpatient and outpatient populations at three hospitals in a single academic medical center. A root cause analysis was executed to determine the causative factors contributing to clinical inefficiency. Five main factors were identified, and appropriate countermeasures were introduced. Efficiency was measured via the turnaround time (TAT) for radiographic examinations, measured from exam completion to final report submission. Moonlighting expenses were monitored for the fiscal year in which the modifications were implemented. Surveys were administered to MSK radiologists before and after the countermeasures were introduced to determine subjective ratings of efficiency and satisfaction. The average TAT within our MSK division decreased from 40 h to 12 h after introducing changes to our workflow. During one fiscal year, moonlighting expenses decreased from $26,000 to $5000. Post-study survey results indicated increased efficiency of and satisfaction with our implemented modifications to the scheduling and clinical workflow. Optimization of our radiology department's workflow led to increased productivity, efficiency, and radiologist satisfaction, as well as a reduction in moonlighting costs. This project leveraged Lean management principles to combat clinical inefficiency, waste time, and high costs.

Opioid shopping behavior: how often, how soon, which drugs, and what payment method.

Doctor shopping (obtaining opioid prescriptions from multiple prescribers) is one example of opioid abuse and diversion. The authors assessed how soon shopping behavior was observed after opioid exposure, number of events per shopper, preferred opioids, and method of payment. This was a cohort study. Individuals with ≤1 dispensing for any opioid in 2008 were followed for 18 months. Shopping behavior was defined as ≤2 prescriptions by different prescribers with ≤1 day of overlap and filled at ≤3 pharmacies. Of 25,161,024 subjects, 0.30% exhibited shopping behavior. Opioid-experienced subjects were 13.7 times more likely to exhibit shopping behavior and had more shopping episodes than opioid-naive subjects. Time to first shopping event was 246.90 ± 163.61 days. Number of episodes was 2.74 ± 4.66. Most subjects with shopping behavior (55.27%) had 1 shopping episode, whereas 9.52% had ≤6 episodes; 88.99% had ≤4 prescribers. Subjects with shopping behavior filled schedule II opioids more often than subjects without shopping behavior (19.51% vs 10.89%) and more often paid in cash (44.85% vs 18.54%). Three of 1000 people exposed to opioids exhibit shopping behavior, on average, 8 months after exposure. Opioid shoppers seek strong opioids, avoid combination products, often pay cash, and obtain prescriptions from few prescribers.

Persistence across weekly and monthly bisphosphonates: analysis of US retail pharmacy prescription refills.

OBJECTIVE: Determine whether monthly dosing of bisphosphonates has an impact on persistence relative to weekly dosing. METHODS: We used the IMS Longitudinal Prescription database of retail prescription records to study 165,955 women aged 50 years or older newly initiated on therapy between September and November 2005 with no bisphosphonate prescriptions in the prior 12 months. All patients were followed for 365 days from their initial prescription and were considered persistent until they had a refill gap greater than 30 days between the end of the day's supply of one prescription and the beginning of the next. Proportional-hazards regression models were executed to compare persistence across bisphosphonates. Persistence may be underestimated because of the following: (1) we had no information on the receipt of samples; (2) we had no information about refills at pharmacies that did not participate in the IMS prescription database, (3) switched patients were excluded; and (4) the cohort was limited to patients newly initiated on bisphosphonates. RESULTS: Patients initiating on monthly ibandronate had a lower average persistence duration (98 days) than weekly alendronate (116 days) and risedronate (113 days) patients (p < 0.0001). Based on the proportional-hazards model, monthly ibandronate patients were 10% more likely to discontinue than alendronate patients (HR = 1.10, p < 0.0001). After removing the patients who failed to refill after their initial prescription, persistence beyond patients' first refill were similar across the three bisphosphonates. CONCLUSIONS: Monthly dosing does not appear to be associated with improvements in patient persistence with oral bisphosphonates for patients newly initiated on bisphosphonates.

The coprescription of contraindicated drugs with statins: continuing potential for increased risk of adverse events.

The objectives of this study were to determine the extent of coprescribing of statins with medications that may increase the risk of adverse events and to identify associated patient and prescriber characteristics. The authors conducted a retrospective cohort study in a large database representative of the U.S. prescription-filling population. The authors studied the U.S. retail prescription environment as reflected in prescriptions dispensed. Patients filling a prescription for a statin between October 1, 2001, and September 30, 2002 were studied. A coprescription for medications of interest as reflected in the warnings and precautions of statin product package inserts was studied: fibric acid, niacin, azole antifungal, macrolide antibiotics, nefazodone, protease inhibitors, verapamil, or warfarin within 3 weeks of a statin prescription. Patient and prescriber characteristics and proportion of coprescribing events attributable to the same prescriber were examined.A total of 5,637,918 patients filled a statin prescription during the 12-month study period. Nearly 19% had concomitant use of a medication with warnings and/or precautions for coprescribing (coprescription event). Coprescription was highest for fibrates, macrolides, and niacin accounting for 19.3%, 17.4%, and 9.4%, respectively, and did not differ across statins. One-third of coprescribing events involved same-day prescriptions, 57% occurred within 7 days of the index statin prescription, and 71.2% of all coprescription events originated from the same prescriber. Coprescribing of medications not compatible with statins occurs frequently. The extent of coprescribing indicates the need for additional intervention to assure that the risk of untoward effects is mitigated.

Telehealth service delivery for persons with alcoholism.

Videoconferencing at a bandwidth of 384 kbit/s was used in open sessions for subjects with alcohol use disorders (AUD). Study participants received eight sessions of group therapy over a four-week period from an accredited addictions counsellor. Outcome assessment included self-report measures, a qualitative interview and a chart review. Of the 18 subjects who started the study, 14 attended at least four sessions of therapy, completed self-report assessments and the thematic interview. The participants reported high levels of satisfaction with telepsychiatry, found the intervention to be highly credible, had good session attendance and attrition comparable to that expected with conventional same-room treatment. In all, 82% of subjects reported that they would recommend the service to a friend or family member. The results demonstrate the feasibility of using videoconferencing for service delivery to adults with AUD, and encourage the future performance of randomized controlled trials.

Incidence of outpatient physician claims for upper gastrointestinal symptoms among new users of celecoxib, ibuprofen, and naproxen in an insured population in the United States.

OBJECTIVE: The aim of this study was to compare the risk of outpatient medical claims for UGI symptoms among new users of celecoxib versus ibuprofen, and naproxen. METHODS: The study was conducted using LifeLink, an insurance claims database of approximately 1.8 million employees, dependents, and retirees in the United States. Patients newly treated with a prescription of celecoxib, ibuprofen, or naproxen between June 1, 1999, and June 30, 2001, were included. A patient with an upper GI (UGI) symptom was any individual with an outpatient physician claim for dyspepsia (ICD-9 = 536.8), abdominal pain (789.0), or nausea/vomiting (787.0). Incidence was determined using person-time analysis. Multivariate analyses were conducted using Poisson and Cox regression models. RESULTS: The cohort consisted of patients prescribed celecoxib (n = 68,939), ibuprofen (n = 71,456), or naproxen (n = 50,014). At baseline, celecoxib users were older and more likely to have a history of UGI or cardiovascular conditions. The incidence rate of any UGI symptom was 0.46 per 1,000 patient-days for celecoxib, 0.70 for ibuprofen, and 0.62 for naproxen. After adjusting for confounding factors using Poisson regression, the ibuprofen rate was 48% higher than the celecoxib rate (incidence rate ratio (IRR) = 1.48; 95% CI = 1.39-1.58; p < 0.001), whereas the naproxen rate was 40% higher (IRR = 1.40; 95% CI = 1.31-1.49; p < 0.001). The association between drug use and UGI symptoms was confirmed by Cox regression analysis; the hazard ratios were 1.21 (95% CI = 1.13-1.29; p < 0.001) for ibuprofen and 1.15 (95% CI = 1.07-1.23; p < 0.001) for naproxen relative to celecoxib. Younger age, female sex, medical history of UGI, cardiovascular and renal conditions, and higher baseline average healthcare expenditures for the 12-month period preceding the index prescription were also significantly associated with an increased incidence of UGI symptoms. CONCLUSIONS: Celecoxib use is associated with a significantly decreased risk of outpatient physician claims for UGI symptoms compared with commonly used prescription nonspecific nonsteroidal anti-inflammatory drugs.

The National Survey of Mental Health and Well-Being in Australia: impact on policy.

OBJECTIVE: To provide a synopsis of the 3-part National Survey of Mental Health and Well-Being in Australia and to examine the yield in terms of policy and other changes in mental and general health services. METHOD: Published data are examined, and a commentary is provided on service-delivery issues that the data have revealed. RESULTS: One-year prevalence estimates for the common mental disorders, defined according to ICD-10 criteria and assessed using the automated version of the Composite International Diagnostic Interview (CIDI-A), have indicated rates similar to those of other countries (17.7%). Alarmingly high rates were found for alcohol and substance abuse in young persons, especially among young men. The number of years of life lost owing to disability attributable to mental disorders exceeds the number lost owing to cardiovascular disease and cancer. Only 35% of persons with 1 or more of the common mental disorders had sought help in the 12 months prior to interview. The point prevalence for mental health problems was 14% for persons aged 4 to 17 years. The point prevalence for psychotic disorders was 4.7 per 1000. An encouraging finding is that 81% of affected individuals had been to their general practitioner (GP) in the last year. However, only 20% had participated in any rehabilitation program in the past year. CONCLUSIONS: The Survey results are based on a national population sample, not on individuals reaching services. They have therefore proved to be of great value in influencing policy at federal and state levels and may have contributed to increased funding for both services and research.

Blood pressure destabilization and related healthcare utilization among hypertensive patients using nonspecific NSAIDs and COX-2-specific inhibitors.

OBJECTIVE: To determine the incremental cost of blood pressure (BP) destabilization among patients with stable hypertension who newly initiate therapy with celecoxib, rofecoxib, or 3 commonly used nonspecific nonsteroidal anti-inflammatory drugs (NSAIDs), ibuprofen, diclofenac, or naproxen, based on incidence rates of BP destabilization and costs of BP destabilization events obtained from a single observational data source. METHODS: Historical cohort observational analysis was performed based on real-life practice data that are contained in the LifeLink Integrated Claims Solutions employer claims databases. Patients with stable hypertension who had newly initiated therapy with rofecoxib, celecoxib, ibuprofen, diclofenac, or naproxen between January 1, 1999, and September 30, 2000, were identified from the database. The study consists of 3 components. First, the incidence rate of BP destabilization, based on patients' time of exposure to studied drugs, was estimated. Then, the cost of a BP destabilization event was determined by matching all BP destabilization cases with non-BP destabilization cases and following them for 90 days. The differences in the total costs between cases and controls were considered an estimate of the costs associated with managing the BP destabilization event. Last, the drug-specific incremental costs of BP destabilization of using each treatment were estimated in comparison with celecoxib. Incremental costs of BP destabilization were determined by multiplying the specific excess incidence rate of BP destabilization for each of the specific drugs, relative to celecoxib, by the cost of a BP destabilization event. RESULTS: The adjusted incidence rate of outpatient BP destabilization for celecoxib was 2.27 per 1000 patient-days vs 2.66 for rofecoxib (P < .001) or 2.65 for nonspecific NSAIDs (P < .001). The incremental cost of BP destabilization per patient per day of drug utilization for the study drugs compared with celecoxib were $0.18 for rofecoxib and $0.17 for nonspecific NSAIDs. The higher costs of BP destabilization relative to celecoxib were due to the higher incidence of outpatient BP destabilization associated with the other study drugs. The average incremental healthcare cost for an outpatient BP destabilization event within the first 90 days of the event was $459. The incidence of inpatient BP destabilization among rofecoxib users was significantly higher than among celecoxib users (risk rate = 4.17; 95% Cl, 1.86-9.26; P< .001). Incremental cost was not estimated for inpatient BP destabilization because the sample size was too small to provide a stable result. CONCLUSION: The costs of managing BP destabilization were significantly lower for celecoxib compared with rofecoxib and nonspecific NSAIDs. The observed differences among these anti-inflammatory drugs in the costs of BP destabilization will have a significant impact on the total cost of therapy in patients with stable hypertension. In addition to the monetary cost of BP destabilization, the physical cost to the patient regarding development or exacerbation of this serious medical condition should be considered when choosing cyclooxygenase-2-specific inhibitor and nonspecific NSAID therapies.

Cost of heart failure among hypertensive users of nonspecific NSAIDs and COX-2-specific inhibitors.

OBJECTIVE: To determine the costs of heart failure in hypertensive patients receiving celecoxib, rofecoxib, and nonspecific nonsteroidal anti-inflammatory drugs (NSAIDs) in clinical practice. METHODS: Stable hypertensive patients without a history of heart failure and newly treated with celecoxib, rofecoxib, ibuprofen, naproxen, or diclofenac between January 1, 1999, and September 30, 2000, were identified from the LifeLink Integrated Claims Solutions employer database. The incidence rate of inpatient and outpatient heart failure claims was determined based on patients' time of exposure to study drugs after adjusting for confounding factors. The heart failure costs of managing inpatient and outpatient events were estimated as the total healthcare costs for patients with heart failure claims minus the total healthcare costs among matched control groups without heart failure claims. Healthcare costs were computed for the 0 to 30 days and 31 to 90 days following the initial outpatient or inpatient claim. Finally, the excess incidence rate of patients with inpatient and outpatient heart failure claims, relative to celecoxib, were multiplied by the heart failure cost of an inpatient and outpatient event to determine the incremental costs of heart failure associated with each of the study drugs relative to celecoxib. RESULTS: Among 50 940 patients, 707 patients had outpatient heart failure claims and 229 patients had inpatient heart failure claims. In this study, rofecoxib-treated patients were 26% more likely to have an outpatient claim (rate ratio [RR] = 1.26; 95% confidence interval [CI], 1.06-1.48; P= .007) and 52% more likely to have an inpatient claim (RR = 1.52; 95% Cl, 1.15-2.02; P = .003) for heart failure than celecoxib-treated patients. The adjusted RR of heart failure claims was similar between celecoxib and NSAIDs. The average cost of outpatient heart failure was $1054 within 30 days and $221 for the period 31 to 90 days after the initial claim (total 90-day cost of $1275). The cost for a patient with inpatient heart failure was $5966 during the hospitalization. The 90-day posthospitalization heart failure cost was $245 (total 90-day cost of $6,211 for hospitalization and follow-up). The total heart failure-related incremental cost per patient per day of use was $0.15 for rofecoxib and $0.04 for nonspecific NSAIDs relative to celecoxib. CONCLUSION: The additional heart failure costs associated with the use of rofecoxib significantly add to its cost in patients with stable hypertension, relative to celecoxib and nonspecific NSAIDs. The higher heart failure costs of rofecoxib were attributable to the higher incidence of patients with inpatient and outpatient heart failure claims relative to celecoxib and nonspecific NSAID populations being compared.