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Cost and utilization: no longer taboo topics
One center reduces the number of tests ordered

Keywords: Hospital physicians take steps to curb the number of X-rays and CT scans they order


by Phyllis Maguire



Published in the October 2012 issue of Today's Hospitalist

WHEN IT COMES TO ORDERING TESTS, do you know how much those tests cost or whether you order a lot more (or fewer) than your colleagues? And how do your X-ray and CT scan orders affect your patients in terms of radiation exposure?

When researchers with the hospitalist service at University of California, San Francisco (UCSF), first considered those questions, they got a rude awakening. Using national data, they learned that 90% of academic medicine services ordered fewer chest X-rays than they did. They also realized that between 30% and 40% of
"In decades past, talking about cost was considered voodoo."

ľNiraj Sehgal, MD, MPH
University of California, San Francisco

other services ordered fewer radiology tests overall than UCSF's own medicine service.

To tackle those problems, researchers implemented a two-pronged intervention. In the first phase, which lasted two months, researchers educated housestaff and attendings rotating onto the medicine service about the costs and utilization rates of X-rays (both chest and body) and CT scans (body and head). The second phase likewise lasted two months and gave physicians information about the radiation exposure associated with ordered X-rays and CT scans.

When the number of orders during each phase was compared to baseline, the authors found major differences. The first intervention produced a 19.8% drop in the number of tests ordered, while the second intervention garnered a reduction of 9.5%. Estimated annual savings to the hospital topped $108,000 and $78,000 respectively. And housestaff surveys indicated an increased awareness of testing costs.

"Residents are now much more receptive to such initiatives than I would have been 15 years ago in my residency," says hospitalist Niraj Sehgal, MD, MPH, senior author of the study, which was posted online in August by Archives of Internal Medicine. "This work is going to become much more prevalent as we expand quality improvement beyond quality metrics and to better value."

Dr. Sehgal, who is associate chair for quality and safety in UCSF's department of medicine, talked to Today's Hospitalist about the initiative.

Were you surprised by the results?
I was surprised by the degree of the impact, but not by how readily the concept was embraced. I think that partly reflects the intervention, but it also reflects a shifting culture with an increased focus on health care value and cost of care.

We didn't have to spend energy getting buy-in on why we should care about cost, so the culture now is quite different. In decades past, interventions like this were not successful, and talking about cost was considered voodoo. So I think we're shifting into a different place, particularly with all the focus on health care value in recent months.

Your biggest drop was in the number of chest X-rays ordered. Why are those so overused?
That's a partly unanswered question. Our study was a global assessment of chest X-ray ordering, so we didn't drill down into utilization by individual teams or physicians or by clinical conditions. You could envision a much more targeted intervention looking at, say, daily chest X-ray use in intensive care patients. We're exploring that because there is good evidence that daily chest X-rays in that setting are unnecessary.

We did compare our baseline data to similar academic services through utilization data from the University Health Consortium (UHC). Because chest X-rays are the most frequent radiology test ordered, we hoped focusing on "do we really need this test and will it have an impact on our management?" would reduce utilization, and it did.

How did you educate physicians in each study phase?
We sent e-mails to attendings and housestaff with information on local utilization and cost data. We also gave attendings an educator's facilitation guide, which encouraged them to talk about these topics. The guide included data, but also a script with questions to prompt a dialogue during teaching rounds.

And we put up flyers and posters, some of which had a rough charge per case and comparisons to the UHC data. That comparison made people avoid the easy response, which is often "our patients are sicker so need more tests" argument.

How did you determine costs?
The cost piece is a challenge that is not unique to us: trying to figure out what something costs vs. what we charge vs. what patients are billed. It is all over the map, and the estimations we gave in the report were conservative, based on estimates of the direct costs involved.

As we're implementing a new electronic health record, our radiology department is exploring a number of radiology decision-support tools, some of which incorporate costs. But many are focusing on, "Is this the right test for what you want clinically, and does it need to be ordered?"

One recommendation we make in the study is to make better use of clinical support tools. But we haven't yet embedded cost information into our ordering because, frankly, we just went live with CPOE. We have enough kinks to work out before bludgeoning people with more windows.

I think we also have an obligation to engage patients around these decisions. We haven't done that, partly because we're not always sure what things cost. Patients often ask me, "How much is this test?" and it's not always easy to get that answer. We need to figure out a way to make cost information more transparent, not just to providers but to patients. Right now, it's not part of the discussion.

What other tests may doctors order too often or too soon?
That's different in any given practice. That's why many specialty societies are contributing to the ABIM Foundation's Choosing Wisely campaign, to identify tests and procedures that may be overused.

For primary care, maybe it's the use of MRIs in low back pain. In the hospital, it may be how to build a computerized record that stops us from ordering standard daily labs because we know that many patients don't need a full lab every day. And do all patients who come in with new kidney failure need an ultrasound of their kidneys?

This is an emerging area that will continue to grow whenever we use diagnostic testing. It also extends to getting the right number of consultants and into many different areas on how we use resources.

In the study, we recommend auditing and giving physicians feedback, but there often isn't great evidence for whether or not a test is indicated. One approach is through what many refer to as variability work. Rather than making a judgment on whether a physician is following guidelines, pointing out variability can be very effective. There shouldn't be a five-degree standard deviation difference between how one person practices and another.

How has this changed your practice?
Just as I teach residents about appropriate antibiotics in pneumonia, I make cost and utilization now a normal part of the discussion. When residents order tests, that's the time to say, "Let's talk about it. Why do you want to order a repeat chest X-ray, and what are the benefits, risks and costs of doing that?" I try to promote that dialogue and to practice what I teach.

Phyllis Maguire is Executive Editor of Today's Hospitalist.

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