Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality.

IMPORTANCE: Transformation of US health care from volume to value requires meaningful quantification of costs and outcomes at the level of individual patients. OBJECTIVE: To measure the association of a value-driven outcomes tool that allocates costs of care and quality measures to individual patient encounters with cost reduction and health outcome optimization. DESIGN, SETTING, AND PARTICIPANTS: Uncontrolled, pre-post, longitudinal, observational study measuring quality and outcomes relative to cost from 2012 to 2016 at University of Utah Health Care. Clinical improvement projects included total hip and knee joint replacement, hospitalist laboratory utilization, and management of sepsis. EXPOSURES: Physicians were given access to a tool with information about outcomes, costs (not charges), and variation and partnered with process improvement experts. MAIN OUTCOMES AND MEASURES: Total and component inpatient and outpatient direct costs across departments; cost variability for Medicare severity diagnosis related groups measured as coefficient of variation (CV); and care costs and composite quality indexes. RESULTS: From July 1, 2014, to June 30, 2015, there were 1.7 million total patient visits, including 34 000 inpatient discharges. Professional costs accounted for 24.3% of total costs for inpatient episodes ($114.4 million of $470.4 million) and 41.9% of total costs for outpatient visits ($231.7 million of $553.1 million). For Medicare severity diagnosis related groups with the highest total direct costs, cost variability was highest for postoperative infection (CV = 1.71) and sepsis (CV = 1.37) and among the lowest for organ transplantation (CV ≤ 0.43). For total joint replacement, a composite quality index was 54% at baseline (n = 233 encounters) and 80% 1 year into the implementation (n = 188 encounters) (absolute change, 26%; 95% CI, 18%-35%; P < .001). Compared with the baseline year, mean direct costs were 7% lower in the implementation year (95% CI, 3%-11%; P < .001) and 11% lower in the postimplementation year (95% CI, 7%-14%; P < .001). The hospitalist laboratory testing mean cost per day was $138 (median [IQR], $113 [$79-160]; n = 2034 encounters) at baseline and $123 (median [IQR], $99 [$66-147]; n = 4276 encounters) in the evaluation period (mean difference, -$15; 95% CI, -$19 to -$11; P < .001), with no significant change in mean length of stay. For a pilot sepsis intervention, the mean time to anti-infective administration following fulfillment of systemic inflammatory response syndrome criteria in patients with infection was 7.8 hours (median [IQR], 3.4 [0.8-7.8] hours; n = 29 encounters) at baseline and 3.6 hours (median [IQR], 2.2 [1.0-4.5] hours; n = 76 encounters) in the evaluation period (mean difference, -4.1 hours; 95% CI, -9.9 to -1.0 hours; P = .02). CONCLUSIONS AND RELEVANCE: Implementation of a multifaceted value-driven outcomes tool to identify high variability in costs and outcomes in a large single health care system was associated with reduced costs and improved quality for 3 selected clinical projects. There may be benefit for individual physicians to understand actual care costs (not charges) and outcomes achieved for individual patients with defined clinical conditions.

Rivaroxaban for the Long-term Treatment of Spontaneous Ovarian Vein Thrombosis Caused by Factor V Leiden Homozygosity.

OBJECTIVE: To report a case where rivaroxaban was used in the management of an ovarian vein thrombosis and to briefly review the literature, pathophysiology, and clinical implications therein. CASE SUMMARY: A 30-year-old previously healthy woman was diagnosed with acute, spontaneous, left-ovarian vein thrombosis (OVT) with proximal extension into the renal vein. After initial catheter-directed thrombolysis with tPA, angioplasty of the left renal vein, and heparinoid treatment, rivaroxaban was begun for long-term anticoagulation. Three months after her index event she was symptom free, with complete resolution of her thrombosis and no adverse effects or bleeding complications from rivaroxaban. To our knowledge, this is the first report of OVT successfully treated with rivaroxaban. DISCUSSION: OVT is a rare but potentially fatal cause of abdominal pain that may pose diagnostic and therapeutic dilemmas. Factor V Leiden (FVL) homozygosity, an uncommon but severe inherited thrombophilia, increases the risk of thrombosis by approximately 50- to 80-fold. This case report and accompanying literature review highlight important clinical pearls related to the diagnosis and management of OVT and inherited thrombophilias. CONCLUSIONS: This clinical vignette adds to the published literature suggesting that novel oral anticoagulants, such as rivaroxaban, may eventually emerge as an alternative to vitamin K antagonists for the treatment of extra-axial thromboses. Reporting these cases is important because their prevalence is low outside of specialized referral centers, and thus, dissemination of these experiences may help other providers in treating their patients.

Modified early warning score-based clinical decision support: cost impact and clinical outcomes in sepsis.

OBJECTIVE: The objective of this study was to assess the clinical and financial impact of a quality improvement project that utilized a modified Early Warning Score (mEWS)-based clinical decision support intervention targeting early recognition of sepsis decompensation. MATERIALS AND METHODS: We conducted a retrospective, interrupted time series study on all adult patients who received a diagnosis of sepsis and were exposed to an acute care floor with the intervention. Primary outcomes (total direct cost, length of stay [LOS], and mortality) were aggregated for each study month for the post-intervention period (March 1, 2016-February 28, 2017, n = 2118 visits) and compared to the pre-intervention period (November 1, 2014-October 31, 2015, n = 1546 visits). RESULTS: The intervention was associated with a decrease in median total direct cost and hospital LOS by 23% (P = .047) and .63 days (P = .059), respectively. There was no significant change in mortality. DISCUSSION: The implementation of an mEWS-based clinical decision support system in eight acute care floors at an academic medical center was associated with reduced total direct cost and LOS for patients hospitalized with sepsis. This was seen without an associated increase in intensive care unit utilization or broad-spectrum antibiotic use. CONCLUSION: An automated sepsis decompensation detection system has the potential to improve clinical and financial outcomes such as LOS and total direct cost. Further evaluation is needed to validate generalizability and to understand the relative importance of individual elements of the intervention.

Improving Physician Communication With Patients as Measured by HCAHPS Using a Standardized Communication Model.

Physicians often fail to communicate well with patients. The objective of this retrospective controlled interrupted time series study was to evaluate the impact of a standardized communication intervention to improve physician communication. All patients ages 18 years or older (N = 7739 visits) admitted to University of Utah Health Care in Salt Lake City, Utah, from July 1, 2012, to June 31, 2014, were included. Obstetrics, rehabilitation, and psychiatric patients were excluded. The primary outcome was the percentage of patients who answered "Always" to all HCAHPS questions regarding physician-patient communication. Among the intervention group, the primary outcome increased from 56% to 63% ( P = .014, N = 1021) while remaining stable for the control group (65% to 66%, P = .6, N = 6718). The downward trend reversed after the intervention (-0.6% to +1.7% per month, P < .001). Standardized communication was associated with improvement in physician communication HCAHPS scores.