From the 2018 HVPAA National Conference
Pam Johnson (Hopkins), Amit Pahwa (Johns Hopkins Hospital), Lenny Feldman (Johns Hopkins Hospital), Michael Borowitz (Johns Hopkins Hospital), Trushar Dungarani (Howard County General Hospital), Clare Rock (Johns Hopkins Hospital), Ken Lee (Johns Hopkins Hospital), Steve Park (Johns Hopkins Hospital), Renee Demski (Johns Hopkins Hospital), Roy Ziegelstein (Johns Hopkins School of Medicine), Redonda Miller (Johns Hopkins Hospital)
Background
A high value care committee was created to reduce low value practice across 5 hospitals and a large community practice. Designed to harmonize work being done in silos, the provider-led committee directs initiatives to decrease unnecessary lab tests, imaging exams and medications.
Objectives
To describe how quality-driven, value-improvement initiatives can be successfully scaled, detail the implications for patients, payers and hospitals, and emphasize the importance of multispecialty provider-led teams.
Methods
Committee design
In 2016, a high value care committee was created by institutional leadership, with 5 physician directors appointed from hospital medicine, radiology and lab/pathology. The committee includes physician representatives from all 5 hospitals and teams from value analytics, informatics and finance. Evidence-based initiatives to target low value laboratory and imaging tests were launched beginning October 2016.
Target tests
Lab
Initiatives to reduce 5 low value labs piloted in the Department of Medicine were advanced across the health system:
- Folic acid
- HCV viral load
- HCV genotype
- C. Difficile
- CK-MB
Imaging
Guided by CMS appropriateness data, 3 overutilized imaging exams were targeted at 1 hospital:
- Lumbar spine MRI for low back pain
- Combined head and sinus CT
- Abdominal CT with and without IV contrast
Interventions
The range of interventions included education, modifying POE in the EMR, clinical decision support (CDS), imaging protocol changes and cross-specialty collaboration.
Lab
- educational messages in EPIC without hard stops (advanced October 2016)
- removal of CK-MB from order sets at 1 hospital that still used (January 2017)
- educational One Minute Guides® written by house staff (prior to 2016)
Imaging
- CDS in the EMR to guide ordering of advanced imaging (2015), subsequently enhanced by educational message when providers order L-spine MRI for uncomplicated low back pain (July 2017)
- multi-specialty collaboration to develop ordering guidelines for combined head and sinus CT (July 2016)
- radiology modified utilization of CT with and without IV contrast (February 2017)
- CME/CE courses in best practice imaging exam selection for ordering physicians and advanced practice providers (October 2017)
Assessments
- utilization (ordering volume)
- appropriateness (CMS defined acceptable ICD-10 codes)
- costs (hospital costs, charges to patients & payers)
Results
Utilization & appropriateness
For FY-18, 3 of 5 lab initiatives met expectations (5% reduction), while 1 fell short and ordering of 1 lab increased. In FY-19, lab ordering demonstrated unexpected progressive or continued declines.
Outpatient L-spine MRI outside of acceptable CMS indications has declined each year (Figure 1), with 15% decrease in July 2017-Feb 2018 compared to same period in 2016-17. Unwarranted combined head and sinus CT initially declined but plateaued due to need for a unique neurosurgery referral base. Radiology departmental protocol modification resulted in dramatic and sustained utilization of abdominal CT with and without IV contrast (Figure 2).
Costs
For FY-18, charge reductions in 1 hospital reached $1,700,000 and cost reductions totaled $68,000. For the 1st 6 months of FY-19, charge reductions were $1,500,000 and cost reductions $71,000.
Conclusion
A multispecialty, provider-led team can increase patient care quality and safety by reducing unnecessary tests and decrease costs for patients, payers and hospitals. Interventions must be tailored to the target test.
Implications for the Patient
Reducing unnecessary tests increases quality and safety by protecting patients from unwarranted risk, improves efficiency of care and reduces patients’ total cost of care.
