Reducing Unneeded Clinical Variation in Sepsis and Heart Failure Care to Improve Outcomes and Reduce Cost: A Collaborative Engagement with Hospitalists in a MultiState System
OBJECTIVE: To (1) measure hospitalist care for sepsis and heart failure patients using online simulated patients, (2) improve quality and reduce cost through customized feedback, and (3) compare patient-level outcomes between project participants and nonparticipants.
METHODS: We conducted a prospective, quasi-controlled cohort study of hospitalists in eight hospitals matched with comparator hospitalists in six nonparticipating hospitals across the AdventHealth system. We provided measurement and feedback to participants using Clinical Performance and Value (CPV) vignettes to measure and track quality improvement. We then compared length of stay (LOS) and cost results between the two groups.
RESULTS: 107 providers participated in the study. Over two years, participants improved CPV scores by nearly 8% (P < .001), with improvements in utilization of the three-hour sepsis bundle (46.0% vs 57.7%; P = .034) and ordering essential medical treatment elements for heart failure (58.2% vs 72.1%; P = .038). In study year one, average LOS observed/expected (O/E) rates dropped by 8% for participants, compared to 2.5% in the comparator group, equating to an additional 570 hospital days saved among project participants. In study year two, cost O/E rates improved from 1.16 to 0.98 for participants versus 1.14 to 1.01 in the comparator group. Based on these improvements, we calculated total cost savings of $6.2 million among study participants, with $3.8 million linked to system-wide improvements and an additional $2.4 million in savings attributable to this project.
CONCLUSIONS: CPV case simulation-based measurement and feedback helped drive improvements in evidence-based care that translated into lower costs and LOS, above-and-beyond other improvements at AdventHealth.
© 2019 Society of Hospital Medicine
Sepsis and heart failure are two common, costly, and deadly conditions. Among hospitalized Medicare patients, these conditions rank as the first and second most frequent principal diagnoses accounting for over $33 billion in spending across all payers.1 One-third to one-half of all hospital deaths are estimated to occur in patients with sepsis,2 and heart failure is listed as a contributing factor in over 10% of deaths in the United States.3
Previous research shows that evidence-based care decisions can impact the outcomes for these patients. For example, sepsis patients receiving intravenous fluids, blood cultures, broad-spectrum antibiotics, and lactate measurement within three hours of presentation have lower mortality rates.4 In heart failure, key interventions such as the appropriate use of ACE inhibitors, beta blockers, and referral to disease management programs reduce morbidity and mortality.5
However, rapid dissemination and adoption of evidence-based guidelines remain a challenge.6,7 Policy makers have introduced incentives and penalties to support adoption, with varying levels of success. After four years of Centers for Medicare and Medicaid Services (CMS) penalties for hospitals with excess heart failure readmissions, only 21% performed well enough to avoid a penalty in 2017.8 CMS has been tracking sepsis bundle adherence as a core measure, but the rate in 2018 sat at just 54%.9 It is clear that new solutions are needed.10
AdventHealth (formerly Adventist Health System) is a growing, faith-based health system with hospitals across nine states. AdventHealth is a national leader in quality, safety, and patient satisfaction but is not immune to the challenges of delivering consistent, evidence-based care across an extensive network. To accelerate system-wide practice change, AdventHealth’s Office of Clinical Excellence (OCE) partnered with QURE Healthcare and Premier, Inc., to implement a physician engagement and care standardization collaboration involving nearly 100 hospitalists at eight facilities across five states.
This paper describes the results of the Adventist QURE Quality Project (AQQP), which used QURE’s validated, simulation-based measurement and feedback approach to engage hospitalists and standardize evidence-based practices for patients with sepsis and heart failure. We documented specific areas of variation identified in the simulations, how those practices changed through serial feedback, and the impact of those changes on real-world outcomes and costs.
METHODS
Setting
AdventHealth has its headquarters in Altamonte Springs, Florida. It has facilities in nine states, which includes 48 hospitals. The OCE is comprised of physician leaders, project managers, and data analysts who sponsored the project from July 2016 through July 2018.
Study Participants
AdventHealth hospitals were invited to enroll their hospitalists in AQQP; eight AdventHealth hospitals across five states, representing 91 physicians and 16 nurse practitioners/physician’s assistants (APPs), agreed to participate. Participants included both AdventHealth-employed providers and contracted hospitalist groups. Provider participation was voluntary and not tied to financial incentives; however, participants received Continuing Medical Education credit and, if applicable, Maintenance of Certification points through the American Board of Internal Medicine.
