From the 2018 HVPAA National Conference
Juan Javier-DesLoges (Yale New Haven Health System), Donald Woods (Yale New Haven Health System), Katelyn Johnson (Yale New Haven Health System), Campbell Bryson (Yale New Haven Health System), Rachel Zarro (Yale New Haven Health System), Piruz Motamedinia (Yale New Haven Health System), Patrick Kenney (Yale New Haven Health System)
Ureteral stents are temporary devices to relieve obstruction, but risk being lost. Excessive dwell time leads to obstruction, infection, and kidney loss. Though a clinical commodity, stent cost varies substantially. In our health system, there was substantial baseline variability in device utilization and cost, without suspected clinical benefit.
We describe a novel supply chain value program to identify patients lost to follow up and to reduce supply costs. The objective was to reduce supply costs through a synergistic effort to: 1) reduce to two devices and one vendor, 2) direct device choice by a clinically-driven algorithm, and 3) improve contracting price. The project aimed to improve clinical quality through: 1) a barcode-driven accounting system to track stent utilization, and 2) a reporting system to identify stents lost to follow up.
A methodology was created in EPIC to log ureteral stent insertion and removal, with automated reporting of stents implanted for more than 90 days. Starting in January 2015, monthly reports were reviewed and lost patients contacted. We retrospectively reviewed clinical characteristics including age, sex, race, surgical urgency (elective vs. emergent), and insurance status to identify risk of failure to follow-up.
A clinical algorithm was created in which a low cost stent was advised for conditions with expected short dwell time, and use of a higher cost product was limited to chronic obstruction. Renewed contracting efforts were undertaken based on clinical utilization algorithm. Products of the lowest cost vendor were stocked and those of the higher cost vendor were removed.
The two largest vendors accounted for 93% of the overall stent usage at YNHHS at baseline and after the initiative. The remaining stents were specialty products (e.g., urinary diversion stents). Following launch, there was an immediate and sustained conversion of market share to the lower cost vendor. Market share for the dominant vendor decreased from 58% to 11% and marketshare for the preferred vendor increased from 34% to 82%. This resulted in 35.4% reduction in stent cost.
We identified 1,788 patients who underwent ureteral stent placement over the study period. Sixteen patients (0.9%) failed to follow-up for ureteral stent explantation (table 1). Using multivariate logistic regression (table 2), stents placed in an emergent setting (OR 3.5, p=0.018) and black race (OR 4.03, p=0.018) were independent predictors of failure to follow-up. Age, sex, and insurance status were not predictors of follow-up. On average explanted stents were in place for 33.6 days versus 327 days among those patients lost to follow up.
Reducing clinical variability can lead to cost savings via improved contracted price as well as right-sizing use of higher cost products where clinically appropriate. Integration of supply chain and clinical data can identify opportunities to improve care, as demonstrated by capture and resolution of rare events such as devices lost to follow up.
Lost ureteral stents are infrequent but high impact events. Supply chain data collected via EMR facilitates identification of these events prior to renal unit loss. Stents placed in an emergent setting are at a higher risk of loss to follow-up.
Implications for the Patient
Collaboration between supply chain and clinicians can identify opportunities to improve clinical quality and decrease costs of care, leading to improved value.