One energetic hospitalist, lamenting a "vast culture of overuse and waste," is working with a team to rid his hospital of some unnecessary operational habits that evidence says should be halted.
What can the iCal, a $20 calcium blood test previously administered to nearly all University of California at San Francisco Medical Center patients—whether they needed it or not—teach hospitals about inappropriate care and waste?
A huge amount, says Christopher Moriates, MD, assistant clinical professor of UCSF's division of hospital medicine.
Just one year out of residency, this energetic hospitalist is trying to change much about the culture of his acute care world, not just with peer education about this largely worthless test, but about several other operational habits that evidence says hospitals should break. UCSF stopped doing iCals on all patients about just over a year ago.
Moriates, 31, has had nearly a dozen articles published in national medical journals such as JAMA and Health Affairs, and in textbooks, and is an active member of his professional society in hospitalist medicine.
"It always drove me crazy to see all the things we did in the hospital that just didn't seem to make any sense, and the vast culture of overuse and waste," Moriates explains.
As he and some colleagues "began to review cases and identify the gaps between the evidence base and our practices, it was a natural extension for me to start thinking about how we operationalize these ideals, and start to tackle the rampant overuse and unnecessary testing in hospitals."
Preliminary results presented recently at a Society for Hospital Medicine conference indicate use of the iCal at UCSF has dropped by 50% after about six months. Use of nebulizers, which require a respiratory therapist, after the first 24 hours, was also reduced by more than 50% with a project called Nebs No More After 24. And inappropriate stress ulcer prophylaxis was reduced by more than 25% in the ICU.
At least three other interventions are underway with optimistic results not yet ready for report, including an effort to move appropriate patients from step-down units to regular inpatient beds faster, to transition appropriate patients from intravenous to oral medications more quickly, and to remove IVs when not clinically indicated.
The UCSF Cost Awareness curriculum, which Moriates designed while still a resident, has grown to include a six-pronged project run by the High Value Care Committee. This is a group of 20 doctors, co-chaired by Moriates, which is trying to trim institutionalized, but wasteful practices throughout UCSF. And spread the word to other hospitals too.
But first, a little more explanation about the $20 iCal. Moriates says that at UCSF until May of 2012, and still at many other hospitals, blood is routinely drawn, sometimes multiple times per patient, for a separate lab process to check levels of ionized calcium, though only a few patients (those with parathyroid disease or end-stage renal disease or who have too high calcium levels due to cancer) really need the test.
"Studies show that outside of these select few patients, you don't need it. Yet we've been ordering it routinely on patients and it's completely wasteful. And it's relatively expensive because it has to be run separately from other blood tests in the lab," Moriates says. Besides, a somewhat less accurate calcium test that costs $.50 can signal any problems.
Fast forward a year. A change in the computer ordering set combined with educational efforts have reduced the use of the iCal from 3,660 tests per month in May to just over 1,300 by year's end.
Moriates says he's calculated $150,000 in annual savings in reduced iCal costs, which he admits "is not a ton of money." But the real value is much greater.
"This has been a marker of overuse. When we all agree that this test is unnecessary, we cut it, and then people start thinking about other labs they order. We think there's a big carry-over effect, changing the culture of how people work because they start thinking about what they're ordering."
Although the launch of an electronic ordering system last year and recognition of Choosing Wisely initiatives from the American Board of Internal Medicine Foundation must take part of the credit, Moriates says early financial data indicates direct costs for all labs on the hospital medicine service are down 10% this fiscal year.
Moriates says that to undertake such an effort, it's important from the start to make sure doctors and patients understand that "this is not about taking things away from physicians or patients."
"It's about stewardship. We want to increase appropriateness. I don't want to say we're playing wordsmithing games, but this is an important way to frame the issue. We're not taking away patients' nebulizers, We're improving the appropriate use of respiratory therapies."
Eliminating unnecessary care can also reduce the chance of harm, he adds. Repeating calcium level tests may lead to unnecessary augmentation of calcium with IV, which carries risks such as allergic reactions, lower blood pressure and arrhythmia.
"And there is some harm associated with the use of nebulizers," Moriates says. "They can cause arrhythmias, although that's rare." The bigger argument for moving patients more quickly from nebulizers to inhalers in the hospital is to use their inpatient stay to teach them how to use inhalers correctly.
"Studies have shown that patients don't know how to use their inhalers. We send them out of the hospital without knowing, and if we did a better job teaching them they would be less likely to bounce right back to the hospital (as a readmission.)" And that can easily be defined as a potential harm and a cost.
Other projects to reduce unnecessary, potentially harmful care are in the works, Moriates says. These include four projects now listed in the Society of Hospital Medicine's Choosing Wisely Top 5, including moving to a "restrictive" transfusion strategy, avoiding repetitive blood draws when patients' lab work and clinical picture are stable, and not prescribing preventive medications to medical inpatients to prevent stress ulcers unless they're at high risk for GI complications.
Reducing unnecessary echocardiograms, Moriates says, one of the next projects to tackle, could turn out to be a huge money saving effort, because patients who really need to have an echo often have to wait another day for their test. It also may avoid harm because "you end up picking up insignificant changes that lead you to further testing, further procedures," some of which may result in false positives or adverse events.
Moriates says that he hopes the efforts of the High Value Care Committee, while they may result in lower revenue from health plan payers, will lead UCSF to a place that is well positioned for new payment models in a higher quality world.
"Reimbursement mechanisms, the way of the world, is changing," he says. "We are in a tricky time. if you cut your utilization down too much —it all depends on your payer mix, and how many Medicare, Medicaid and privately insured patients you have—you can decrease your revenue.
"But that's only true today, and very soon that's going to change. If you find yourself not putting these mechanisms in place, not changing your culture and physician practice in the hospital, you'll find yourself really flat-footed when the payment system changes."
"We're trying to get out ahead. But it's very clear which way this is going."