Choosing Wisely

When I graduated from nursing school, inpatient care was much different.  We hadn’t heard of things like length of stay.  Patients stayed as long as the physician deemed necessary – a week or a month – it didn’t matter.  Frequently patients underwent testing that had nothing to do with their admitting diagnosis
many times for their convenience.  So you might see a newly diagnosed diabetic have a barium enema done.  Discussing this with the attending physician, you might find out that the patient had some vague GI complaint a few months ago so while he was in the hospital it would get checked out.

Everything changed with the advent of diagnosis related groups (DRGs) according to the article “After the revolution: DRGs at age 30” (Quinn, 2014).  We were told to concentrate on the principal diagnosis and get patients out of the hospital quickly.  Care unrelated to the reason for hospitalization was targeted for elimination.  Physicians were encouraged to reconsider tests and procedures, especially those with high costs.  There were even charts posted in every nurse’s station listing common tests and their cost.  Costs and lengths of stay began to drop.

Today, hospitals are still challenged by inpatient costs.  In speaking with hospital staff, it is clear they are looking at any and all avenues to reduce expenses.  Staffing levels have been reduced, redundant services eliminated and unnecessary “perks” purged.  Yet the need to become more efficient and cost effective continues, if not increased.  It has become clear that care must be redesigned in a way to ensure quality patient care that is cost effective.  Care management cannot be done in the manner it has always been done but rather it needs to be evidence-based.  The key is the physician.  But how does one begin these discussions?

A good place to start may be the American Board of Internal Medicine (ABIM) “Choosing Wisely” campaign (ABIM Foundation, 2014 ).  Conceived as way to spark discussion between physicians and patients, it provides lists of suggestions on tests and procedures that may increase cost but which are unlikely to have an effect on clinical management or patient outcome.  Many of the suggestions focus on outpatient care, which might be useful in the clinic or owned practice arena, are:

• Patients with low back pain and no other red flags (e.g. severe or progressive neurologic deficits) can wait six weeks before imaging is done
• Don’t perform DEXA screening on women under age 65 or men under age 70
• Avoid prescribing antibiotics for patient with sinusitis unless symptoms last for more than 7 days or there is deterioration after initial improvement.

However, there are a number that apply to inpatient care.  A few examples include:

• Avoiding serial blood counts in clinically stable patients as this may cause anemia
• Eschew cardiac stress testing or non-invasive imaging as a pre-op assessment for patients undergoing low-risk, non-cardiac surgery (e.g. cataract removal) as the tests won’t change the outcome
• Elimination of routine pre-op chest x-rays in the absence of clinical suspicion of intrathoracic pathology as these studies rarely provide a change in clinical management.

The physician is key to any redesign effort.  A key component to the AMS Gainsharing Program is the hospital Steering Committee.  The Steering Committee is made up of at least 50% physicians and provides the oversight to the program.  At one recent Steering Committee meeting at Lutheran Medical Center in New York, the Chief Medical Officer started the meeting by distributing binders of information on the Choosing Wisely initiative.  The material was not meant to be prescriptive but rather as a place to open dialogue and spark discussion about how to reconsider the manner in which care was provided.  The participating physicians continue to review and discuss the information.

These are simple ideas that can be used to start a discussion.  Perhaps your hospital is looking at the flow within the Operating room.  Part of your analysis might include a review of pre-operative testing, which is frequently a cause of delays due to missing results.  Asking whether every patient needs to have an x-ray may be a way to get everyone talking.

References

Quinn, K. (2014, March 18). After the Revolution: DRGs at Age 30. Annals of Internal Medicine, pp. 426-429. Retrieved from http://annals.org/article.aspx?articleid=1846643.

ABIM Foundation. (2014, May 1). Unnecessary Tests and Procedures In the Health Care System. Retrieved from http://www.choosingwisely.org/wp-content/uploads/2014/04/042814_Final-Choosing-Wisely-Survey-Report.pdf.