Peter M. Yarbrough

Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs

BACKGROUND Inappropriate laboratory testing is a contributor to waste in healthcare. OBJECTIVE To evaluate the impact of a multifaceted laboratory reduction intervention on laboratory costs. DESIGN A retrospective, controlled, interrupted time series (ITS) study. SETTING University of Utah Health Care, a 500-bed academic medical center in Salt Lake City, Utah. POPULATION All patients 18 years or older admitted to the hospital to a service other than obstetrics, rehabilitation, or psychiatry. INTERVENTION Multifaceted quality-improvement initiative in a hospitalist service including education, process change, cost feedback, and financial incentive. MEASUREMENTS Primary outcomes of lab cost per day and per visit. Secondary outcomes of number of basic metabolic panel (BMP), comprehensive metabolic panel (CMP), complete blood count (CBC), and prothrombin time/international normalized ratio tests per day; length of stay (LOS); and 30-day readmissions. RESULTS A total of 6310 hospitalist patient visits (intervention group) were compared to 25,586 nonhospitalist visits (control group). Among the intervention group, the unadjusted mean cost per day was reduced from

Argatroban Dose Reductions for Suspected Heparin-Induced Thrombocytopenia Complicated by Child-Pugh Class C Liver Disease:

138 before the intervention to

Evidence-based care pathway for cellulitis improves process, clinical, and cost outcomes

123 after the intervention (P < 0.001), and the unadjusted mean cost per visit decreased from

Improving Physician Communication With Patients as Measured by HCAHPS Using a Standardized Communication Model

618 to

Prescribing patterns of target-specific oral anticoagulants: an academic hospital perspective.

558 (P = 0.005). The ITS analysis showed significant reductions in cost per day, cost per visit, and the number of BMP, CMP, and CBC tests per day (P = 0.034, 0.02, <0.001, 0.004, and <0.001). LOS was unchanged and 30-day readmissions decreased in the intervention group. CONCLUSION A multifaceted approach to laboratory reduction demonstrated a significant reduction in laboratory cost per day and per visit, as well as common tests per day at a major academic medical center. Journal of Hospital Medicine 2016;11:348-354.

The use of an automated notification system to identify and address early readmissions by a university hospitalist service

OBJECTIVE: To report our experience of reduced-dose argatroban in a patient with suspected heparin-induced thrombocytopenia (HIT) and Child-Pugh class C liver disease and review the relevant literature to summarize current recommendations on argatroban use in patients with severe liver disease. CASE SUMMARY: A 58-year-old male with Child-Pugh class C liver disease (Model for End-Stage Liver Disease [MELD] score = 31, total bilirubin 4.5 mg/dL) and hemodialysis-dependent renal failure was hospitalized with acute deep vein thrombosis (DVT). Three days after heparin initiation for DVT, he developed thrombocytopenia. Given his heparin exposure (both for treatment of DVT and ongoing hemodialysis), HIT was suspected and all heparinoids were immediately discontinued. Argatroban was initiated for the treatment of HIT while laboratory testing for HIT antibodies and the serotonin release assay were completed. Because of the patients advanced liver disease, the starting dose of argatroban was reduced to 0.2 μg/kg/min, with frequent monitoring of the activated partial thromboplastin time (aPTT) (goal 60–85 seconds). Despite this dose reduction, the aPTT was supratherapeutic. Following further dose reductions, a final argatroban maintenance dose of 0.05 μg/kg/min was necessary for the attainment of goal aPTTs. DISCUSSION: Reducing the starting dose of argatroban to 0.5 μg/kg/min is recommended in patients with liver disease. Nevertheless, this recommended dose is largely based on data from patients with more moderate liver disease (eg, Child-Pugh class A or B), and dosing in more advanced liver disease remains largely unexplored. Patients with more advanced liver disease may require additional dose reductions to avoid supratherapeutic concentrations of anticoagulation agents and to minimize bleeding risk. CONCLUSIONS: This report illustrates the importance of careful selection of argatroban dosing and appropriate aPTT monitoring in patients with severe liver disease. Excessive anticoagulation may precipitate major bleeding complications, placing patients with this complicated disease at undue risk.

Expedited Management of Deep Vein Thrombosis and Acute Pulmonary Embolism

BACKGROUND Cellulitis is a common infection with wide variation of clinical care. OBJECTIVE To implement an evidence-based care pathway and evaluate changes in process metrics, clinical outcomes, and cost for cellulitis. DESIGN A retrospective observational pre-/postintervention study was performed. SETTING University of Utah Health Care, a 500-bed academic medical center in Salt Lake City, Utah. PATIENTS All patients 18 years or older admitted to the emergency department observation unit or hospital with a primary diagnosis of cellulitis. INTERVENTION Development of an evidence-based care pathway for cellulitis embedded into the electronic medical record with education for all emergency and internal medicine physicians. MEASUREMENTS Primary outcome of broad-spectrum antibiotic use. Secondary outcomes of computed tomography/magnetic resonance imaging orders, length of stay (LOS), 30-day readmission, and pharmacy, lab, imaging, and total facility costs. RESULTS A total of 677 visits occurred, including 370 visits where order sets were used. Among all patients, there was a 59% decrease in the odds of ordering broad-spectrum antibiotics (P < 0.001), 23% decrease in pharmacy cost (P = 0.002), and 13% decrease in total facility cost (P = 0.006). Compared to patients for whom order sets were not used, patients for whom order sets were used had a 75%, 13%, and 25% greater decrease in the odds of ordering broad-spectrum antibiotics (P < 0.001), clinical LOS (P = 0.041), and pharmacy costs (P = 0.074), respectively. CONCLUSION The evidence-based care pathway for cellulitis improved care at an academic medical center by reducing broad-spectrum antibiotic use, pharmacy costs, and total facility costs without an adverse change in LOS or 30-day readmissions.

Unintended Consequences of Quality-of-Care Measures

Physicians often fail to communicate well with patients. The objective of this retrospective controlled interrupted time series study was to evaluate the impact of a standardized communication intervention to improve physician communication. All patients ages 18 years or older (N = 7739 visits) admitted to University of Utah Health Care in Salt Lake City, Utah, from July 1, 2012, to June 31, 2014, were included. Obstetrics, rehabilitation, and psychiatric patients were excluded. The primary outcome was the percentage of patients who answered “Always” to all HCAHPS questions regarding physician-patient communication. Among the intervention group, the primary outcome increased from 56% to 63% (P = .014, N = 1021) while remaining stable for the control group (65% to 66%, P = .6, N = 6718). The downward trend reversed after the intervention (−0.6% to +1.7% per month, P < .001). Standardized communication was associated with improvement in physician communication HCAHPS scores.

Application of the DRIP Score at a Veterans Affairs Hospital

Target-specific oral anticoagulants have been rapidly adopted into clinical practice for stroke prophylaxis and venous thromboembolism treatment, raising concerns about off-label prescribing practices. We conducted a retrospective review of consecutive patients prescribed dabigatran, rivaroxaban or apixaban prior to inpatient hospitalization over an 18-month period to examine the off-label prescribing frequency, contraindications and related complications. Chart review included baseline demographics, hospital admitting service, outpatient prescribing service, renal function, therapeutic indication, echocardiographic findings, contraindications, major bleeding events and vital status. We identified 160 patients who received a target-specific oral anticoagulant prior to hospitalization. Over half (53.1%) of the patients received rivaroxaban, 43.7% received dabigatran and 3.1% received apixaban. Atrial fibrillation (68.1%) and venous thromboembolism treatment (25.6%) were the most common indications. Ninety percent of patients had a U.S. Foods and Drugs Administration (FDA)-approved indication for therapy. Major bleeding events occurred in 4.4% of patients. Cardiology was the most common prescribing and admitting service (43.8 and 31.3%), and more frequently adhered to FDA-approved indications (97 vs. 84%, P = 0.01). There were no significant differences between prescribing services regarding major contraindications (P = 0.14) and major bleeding events (P = 0.77). Off-label prescription rates for target-specific oral anticoagulants were infrequent and not associated with increased adverse events.

Reply: Pneumonia Outcome Measures Modified to Address Concerns about Coding-related Biases

Abstract Objectives. To examine the association of an automated physician feedback system prompting physician review of early readmissions with a change in overall readmission rates. Methods. The University of Utah Internal Medicine Hospitalist Service created an automated system to alert discharging providers to any patient readmitted within 30 days. For any 7-day readmission, the physician was asked to complete a survey to describe the admission and discharge and to identify contributing factors to the readmission. Using the University HealthSystem Consortium database, readmission rates were compared prior to and following this intervention. Results. Following the intervention, 30-day readmission rates significantly decreased from 13.93% to 11.99% (p = 0.0298). The 7-day readmission rates decreased as well but the findings were not statistically significant. The discharging physician deemed 45% of the readmissions preventable or probably preventable. Conclusion. Readmissions are common, costly and potentially preventable. This tool for physician audit and feedback and identification of defects contributing to readmissions was associated with a statistically significant decrease in 30-day readmissions. Further investigation is needed to verify these results and evaluate the best mechanism of application.