Jessica C. Dudley

Impact of Provider-led, Technology-enabled Radiology Management Program on Imaging

OBJECTIVE The study objective was to assess the impact of a provider-led, technology-enabled radiology medical management program on high-cost imaging use. METHODS This study was performed in the ambulatory setting of an integrated healthcare system. After negotiating a risk contract with a major commercial payer, we created a physician-led radiology medical management program to help address potentially inappropriate high-cost imaging use. The radiology medical management program was enabled by a computerized physician order entry system with integrated clinical decision support and accountability tools, including (1) mandatory peer-to-peer consultation with radiologists before order completion when test utility was uncertain on the basis of order requisition; (2) quarterly practice pattern variation reports to providers; and (3) academic detailing for targeted outliers. The primary outcome measure was intensity of high-cost imaging, defined as the number of outpatient computed tomography (CT), magnetic resonance imaging (MRI), and nuclear cardiology studies per 1000 patient-months in the payers panel. Chi-square test was used to assess trends. RESULTS In 1.8 million patient-months from January 2004 to December 2009, 50,336 eligible studies were performed (54.1% CT, 40.3% MRI, 5.6% nuclear cardiology). There was a 12.0% sustained reduction in high-cost imaging intensity over the 5-year period (P < .001). The number of CT studies performed decreased from 17.5 per 1000 patient-months to 14.5 (P < .01); nuclear cardiology examinations decreased from 2.4 to 1.4 (P < .01) per 1000 patient-months. The MRI rate remained unchanged at 11 studies per 1000 patient-months. CONCLUSION A provider-led radiology medical management program enabled through health information technology and accountability tools may produce a significant reduction in high-cost imaging use.

Engaging specialists in performance-incentive programs.

Dr. Jeffrey Greenberg and colleagues argue that to have a meaningful impact on the quality of care, pay-for-performance programs and newer-generation quality-incentive programs must engage more specialists. However, engaging these physicians in such programs is challenging for several reasons.

Cost-related medication underuse: Prevalence among hospitalized managed care patients†

BACKGROUND The affordability of prescription medications continues to be a major public health issue in the United States. Estimates of cost-related medication underuse come largely from surveys of ambulatory patients. Hospitalized patients may be vulnerable to cost-related underuse and its consequences, but have been subject to little investigation. OBJECTIVE To determine impact of medication costs in a cohort of hospitalized managed care beneficiaries. METHODS We surveyed consecutive patients admitted to medical services at an academic medical center. Questions about cost-related underuse were based on validated measures; predictors were assessed with multivariable models. Participants were asked about strategies to improve medication affordability, and were contacted after discharge to determine if they had filled newly prescribed medications. RESULTS One-hundred thirty (41%) of 316 potentially eligible patients participated; 93 (75%) of these completed postdischarge surveys. Thirty patients (23%) reported cost-related underuse in the year prior to admission. In adjusted analyses, patients of black race were 3.39 times (95% confidence interval [CI], 1.05 to 11.02) more likely to report cost-related underuse than non-Hispanic white patients. Virtually all respondents (n = 123; 95%) endorsed at least 1 strategy to make medications more affordable. Few (16%) patients, prescribed medications at discharge, knew how much they would pay at the pharmacy. Almost none had spoken to their inpatient (4%) or outpatient (2%) providers about the cost of newly prescribed drugs. CONCLUSIONS Cost-related underuse is common among hospitalized patients. Individuals of black race appear to be particularly at risk. Strategies should be developed to address this issue around the time of hospital discharge.

Improving Adherence to Treatment Guidelines: A Blueprint

Patients with chronic diseases often require complex medication regimens to meet evidence-based treatment guidelines. However, translating evidence-based recommendations into clinical care has proven to be difficult. Several factors-patient adherence, disease complexity, competing medical issues, guideline dissemination, and clinical inertia-are thought to contribute to this problem. In this manuscript, we describe a multidisciplinary ambulatory approach to improve the care of patients with chronic conditions. Our goal was to design an intervention that focused on improving the prescription rates of medications known to reduce cardiovascular-related events and hospital admissions for patients with diabetes mellitus, coronary artery disease, heart failure, chronic kidney disease, or stroke. We also describe the critical lessons we have learned in implementing our intervention, including the successes and barriers we encountered during the project.

Last-minute preoperative cardiology consultations: Epidemiology and impact

To identify clinical predictors of last-minute preoperative cardiology consultations and to evaluate the impact of these consultations on patient care, we performed a retrospective case-control study including all 166 patients who received unscheduled cardiology consultations at the preadmission testing center (PATC) of an urban teaching hospital. Control subjects were 166 patients matched by date and category of surgical procedure. Significant (p < 0.05) independent predictors of last-minute consultations included history of myocardial infarction (odds ratio [OR] = 23.7; 95% confidence interval [CI] = 1.5 to 373), history of chest pain (OR = 15.3; 95% CI = 3.7 to 62.9), history of chronic obstructive lung disease (OR = 5.9; 95% CI = 1.1 to 32.9), prior echocardiography (OR = 3.4; 95% CI = 1.2 to 9.8), and age (OR per decade = 1.1; 95% CI = 1.04 to 1.1). Thus among patients undergoing elective noncardiac surgery, last-minute preoperative consultations are common and are usually precipitated by an abnormal electrocardiogram or history of cardiovascular disease. Last-minute consultations may be preventable if those patients with risk factors for consultation are identified in advance of the preadmission evaluation and referred for elective consultation.

Challenges to implementing expanded team models: lessons from a centralised nurse-led cholesterol-lowering programme

Background Lowering low-density lipoprotein (LDL) cholesterol in patients with diabetes mellitus (DM) and cardiovascular disease (CVD) is critical to lowering morbidity and mortality. To increase the percentage of patients with DM and CVD at target LDL (<100 mg/dL), we launched an expanded team-based quality improvement programme in which centralised registered nurses (RNs) followed a detailed protocol to adjust cholesterol-lowering medications. Despite the growing use of team-based approaches to improve quality of care, little remains known about how best to implement them. Program evaluation To share our experiences and lessons from operating a team-based programme, we conducted a retrospective observational analysis of administrative and clinical data on programme performance. We measured: primary care physician (PCP) and patient acceptance of the programme, number of medication adjustments, change in LDL, per cent of patients achieving target, time to LDL target and the efforts required to achieve these goals. Results Using administrative data, we initially identified 374 potential patients for enrolment. Chart review revealed that 203 (54%) were clinically eligible. PCPs agreed to enrol 74% (150/203) of these patients. Thirty-six per cent of PCP-approved patients (54/150) could not be reached via phone and 5.3% (8/150) declined enrolment. Of patients enrolled (n=64), 50% did not complete the programme. Of those enrolled, median LDL decreased by 21 mg/dL and 52% (33/64) achieved the LDL target. Programme RNs spent 12 023 min on programme activities, of which 44.4% (5539) was related to non-enrolled patients. Conclusions Our adoption of a centralised expanded team-based programme for the management of LDL cholesterol uncovered many barriers to efficiency and success. Even though expanded team programmes may be supported by PCPs, the administrative efforts required to identify, enrol and continually engage eligible patients raise many concerns regarding efficiency and highlight infrastructure changes needed for successful team-based approaches.