HVPAA high value quality improvement initiatives for the 2017-2018 academic year address the 1st pillar of high value health care: diagnostic and therapeutic efficiency. Teams from experienced centers are co-authoring evidence-based guides to reduce unnecessary diagnostics and treatments. The papers include quality and safety outcomes data from value-based Q/I initiatives as well as an implementation blue print (content for educational campaigns and clinical decision support messages). A resident or fellow co-author is a requirement for every guide, in keeping with our mission to engage trainees in high value quality improvement.
Several of the efficiency improvement initiatives improve health care quality and safety, including adherence to American Association of Blood Banks’ Clinical Practice Guidelines and appropriate testing for C. difficile to avoid inappropriate treatment. In addition to publishing implementation guides, the team leaders for these initiatives will direct national campaigns to engage and guide medical centers through the quality improvement process.
For performance improvement in areas of practice without evidence based guidelines, collaborators are designing multicenter quality improvement initiatives. Examples include reducing inappropriate imaging and treatment for noninfectious pulmonary processes misdiagnosed as pneumonia.
A survey of alliance members identified evidence-based initiatives piloted by multiple member institutions, providing sufficient experience-based leadership for national expansion. Many of these initiatives are supported by one or more of the Choosing Wisely® recommendations. Links to clinical practice guides are included where available.
[icon name=”university” class=”” unprefixed_class=””] PILLAR I: DIAGNOSTIC & THERAPEUTIC EFFICIENCY
[icon name=”arrow-circle-right” class=”” unprefixed_class=””] REDUCING UNNECESSARY LABORATORY TESTS
CK-MB in patients with suspected acute coronary syndrome
- ACC/AHA Guidelines for management of patients with unstable angina and non-ST-elevation MI: Executive summary and recommendations
https://circ.ahajournals.org/content/102/10/1193
Implementation Guide Collaborators
Allan Jaffe, MD, Mayo Clinic
Jeff Trost, MD, Roy Ziegelstein, MD & Matt Alvin, MD, MBA (resident), Johns Hopkins School of Medicine
Repeat daily labs on inpatients
Implementation Guide Collaborators
Rodrigo Alban, MD, Cedars Sinai Medical Center
Harry Cho, MD, Icahn School of Medicine at Mt Sinai Medical Center
Amit Pahwa, MD & Kevin Eaton, MD (resident), Johns Hopkins Hospital
Chris Petrilli, MD & Kate Levy, MD (resident), Michigan Medicine
Christine Soong, MD, University of Toronto
Andrew S. Parsons, MD, MPH, University of Virginia
JAMA Internal Medicine Special Communication: Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing
Inappropriate C Difficile testing
- Clinical Practice Guidelines for C Difficile Infection in Adults: 2010 Update by the Society of Healthcare Epidemiology in America and Infectious Diseases Society of America
https://www.cdc.gov/hai/pdfs/cdiff/cohen-idsa-shea-cdi-guidelines-2010.pdf
https://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/cdiff2010a.pdf - American College of Gastroenterology Guidelines for Diagnosis, Prevention and Treatment of Clostridium Difficile Infections
https://gi.org/guideline/diagnosis-and-management-of-c-difficile-associated-diarrhea-and-colitis/
Implementation Guide Collaborators
Karen Carroll, MD, Clare Rock, MD and Masako Mizusawa, MD (fellow), Johns Hopkins Hospital
Surbhi Leekha, MBBS, MPH, and Daniel Morgan, MD, University of Maryland
Nasia Safdar, MD, PhD, University of Wisconsin
Greg Seymann, MD, University of California San Diego
Preoperative labs on low risk patients
- American Society of Anesthesiologists Practice Advisory for Presanesthesia Evaluation
https://www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/practice-advisory-for-preanesthesia-evaluation.pdf - Preoperative Testing Before Noncardiac Surgery: Guidelines and Recommendations from the AAFP
https://www.aafp.org/afp/2013/0315/p414.pdf
Implementation Guide Collaborators
Rodrigo Alban, MD, Cedars Sinai Medical Center
Lia Logio, MD, Grace Sun, MD & Natalia Ivascu, MD, Weill Cornell Medical Center
Lee Goeddel, MD & Jerry Stonemetz, MD, Johns Hopkins Hospital
Alan Curie, MD, University of Rochester
Carol Peden, MD, University of Southern California, Keck
Lori Ryder, MD and Jill Zafar, MD, Yale Medical Center
[icon name=”arrow-circle-right” class=”” unprefixed_class=””] REDUCING UNNECESSARY TELEMETRY
- Practice Standards for Electrocardiographic Monitoring in Hospital Settings An American Heart Association Scientific Statement From the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young
https://circ.ahajournals.org/content/110/17/2721.full
Implementation Guide Collaborators
Lia Logio, MD & Jamuna Krishnan, MD (resident), Weill Cornell Medicine
Amit Pahwa, MD & Calvin Kagan, MD (resident), Johns Hopkins Hospital
Chris Petrilli, MD, & Garth Strohbehn, MD (resident), Michigan Medicine
Greg Seymann, MD & Meera Subash (resident), UCSD
Richard Wardrop, MD, PhD, UNC Chapel Hill
Karli Edholm, MD, University of Utah
[icon name=”arrow-circle-right” class=”” unprefixed_class=””] REDUCING INAPPROPRIATE IMAGING
The HVPAA Radiology Collaborative includes faculty from > 25 academic radiology departments collaborating on the following initiatives:
- Consensus standardized management recommendations based on ACR AC®, ACR incidental finding white papers and society evidence-based guidelines.
- Phase I: lung nodule, thyroid nodule, AAA
- Phase II: adrenal nodule, ovarian cyst, small renal mass
- Phase III: pancreatic cyst, renal cyst
- Harmonizing abdominal CT protocols to reduce unnecessary multiphase imaging as detailed in the new ACR Choosing Wisely® recommendations
- Pooling data to establish benchmarks for emergency department imaging positive exam rates
- Evidence-based diagnostic pathways for the CMS Priority Clinical Areas(CAD/ACS, pulmonary embolism, headache, neck pain, low back pain, shoulder pain, hip pain and lung cancer).
Imaging tests being targeted in multiple academic centers:
- Lumbar spine MRI for uncomplicated low back pain in patients with < 6 weeks of conservative treatment
- ACR Appropriateness Criteria® : Low back pain
https://acsearch.acr.org/docs/69483/Narrative/
- ACR Appropriateness Criteria® : Low back pain
- Routine ICU chest radiographs
- ACR Appropriateness Criteria® : Intensive Care Unit Patients
https://acsearch.acr.org/docs/69452/Narrative/
- ACR Appropriateness Criteria® : Intensive Care Unit Patients
- Inappropriate Chest CTA for pulmonary embolism
- ACR Appropriateness Criteria®: Acute Chest Pain- Suspected Pulmonary Embolism
https://acsearch.acr.org/docs/69404/Narrative/
- ACR Appropriateness Criteria®: Acute Chest Pain- Suspected Pulmonary Embolism
- Brain Imaging (CT, MRI) for chronic headache
- ACR Appropriateness Criteria®: Headache
https://acsearch.acr.org/docs/69482/Narrative/
- ACR Appropriateness Criteria®: Headache
[icon name=”arrow-circle-right” class=”” unprefixed_class=””] REDUCING INAPPROPRIATE TREATMENTS
Transfusions and Blood Management
- AABB Clinical Practice Guidelines
https://www.aabb.org/programs/clinical/Pages/default.aspx
Implementation Guide Collaborators
Moises Auron, MD & Divyajot Sadana, MD (resident), Cleveland Clinic
Steve Frank, MD & Lauren Scher, MD (resident), Johns Hopkins Hospital
Nicole Adler, MD, Frank Volpicelli, MD, Arielle Pratzer, MD (resident) & Harry Saag, MD, New York University Langone Health System
JAMA Internal Medicine Special Communication: Promoting High-Value Practice by Reducing Unnecessary Transfusions With a Patient Blood Management Program
Antibiotics for Asymptomatic Bacteriuria
- Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults
https://academic.oup.com/cid/article-lookup/doi/10.1086/427507
Implementation Guide Collaborators
Shafinaz Akhtar, MD, Crozer Chester Medical Center
Amit Pahwa, MD, Sara Keller, MD, Michael Daniel, MD (intern), Johns Hopkins Hospital
Christine Soong, MD, University of Toronto
JAMA Internal Medicine Special Communication: An Implementation Guide to Reducing Overtreatment of Asymptomatic Bacteriuria
Proton Pump Inhibitor Administration
Implementation Guide Collaborators
Society of Hospital Medicine
Harry Cho, MD, Icahn School of Medicine at Mt Sinai Medical Center
Johns Hopkins Hospital
Nicole Adler, MD, Frank Volpicelli, MD, Arielle Pratzer, MD (resident) & Harry Saag, MD, New York University Langone Health System
Deepak Agrawal, MD, and Arjun Gupta, MD, University of Texas Southwestern
Reducing inappropriate imaging and treatment for noninfectious pulmonary processes misdiagnosed as pneumonia.
Quality Improvement Collaborators
Michael Rothberg, MD, Cleveland Clinic
Brandyn Lau, Ken Lee, PhD, Lenny Feldman, MD, John Eng, MD, Paul O’Rourke, MD, Pam Johnson, MD, Tony Lin, MD, Jenny Townsend, MD, Sara Keller, MD & Sara Cosgrove, MD, representing Infectious Disease, Internal Medicine & Radiology from Johns Hopkins Medicine
Christopher Petrilli, MD, Christopher Grondin, MD & Valerie Vaugh, MD, Michigan Medicine
George Hoke, MD, University of Virginia
[icon name=”arrow-circle-right” class=”” unprefixed_class=””] OPTIMIZING PROCEDURES
Venous Access: Midlines and PICC lines
Quality Improvement Collaborators
Kelvin Hong, MD, Johns Hopkins Hospital
Chris Petrilli, MD & Dave Bozaan, MD, Michigan Medicine
Nicole Adler, MD & Frank Volpicelli, MD, New York University Langone Health System
Deepak Agrawal MD, and Bhavan, MD, University of Texas Southwestern
[icon name=”university” class=”” unprefixed_class=””] PERFORMANCE IMPROVEMENT
Annual recognition will be made for high performing HVPAA members as follows:
Bronze Medalist
Successfully implement 1 value-based Q/I initiative
Silver Medalist
Successfully implement 2-4 value-based Q/I initiatives
Gold Medalist
Successfully implement 5+ value-based Q/I initiatives
[icon name=”university” class=”” unprefixed_class=””] PHASE II
The 2nd phase of implementation will address data from a recent Kaiser Foundation/NYT survey, demonstrating that the 2 biggest contributors to health care debt are hospitalizations and emergency department visits. Accordingly, value-based health care quality improvement efforts will focus on the 4 pillars of high value care designed to reduce hospitalizations, inpatient length of stay, preventable admissions and emergency department visits.
[icon name=”university” class=”” unprefixed_class=””] PILLAR II: QUALITY DRIVEN MEDICAL & SURGICAL PATHWAYS
Pathway Collaboators
Rodrigo Alban, MD, Cedars Sinai Medical Center
Lisa Ishii , MD and Amit Pahwa, MD, Johns Hopkins Hospital
Nicole Adler, MD, Paresh Shah, MD, Frank Volpicelli, MD, Prashant Sinha, MD, New York University Langone Health System