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
Statistical Analyses
We analyzed three primary outcomes: (1) general CPV-measured improvements in each round (scored against evidence-based scoring criteria); (2) disease-specific CPV improvements over each round; and (3) changes in patient-level outcomes and economic savings among AdventHealth pneumonia/sepsis and heart failure patients from the aforementioned improvements. We used Student’s t-test to analyze continuous outcome variables (including CPV, cost of care, and length of stay data) and Fisher’s exact test for binary outcome data. All statistical analyses were performed using Stata 14.2 (StataCorp LLC, College Station, Texas).
RESULTS
Baseline Characteristics and Assessment
A total of 107 AdventHealth hospitalists participated in this study (Appendix Table 1). 78.1% of these providers rated the organization’s focus on quality and lowering unnecessary costs as either “good” or “excellent,” but 78.8% also reported that variation in care provided by the group was “moderate” to “very high”.
At baseline, we observed high variability in the care of pneumonia patients with sepsis (pneumonia/sepsis) and heart failure patients as measured by the care decisions obtained in the CPV cases. The overall quality score, which is a weighted average across all domains, averaged 61.9% ± 10.5% for the group (Table 1). Disaggregating scores by condition, we found an average overall score of 59.4% ± 10.9% for pneumonia/sepsis and 64.4% ± 9.4% for heart failure. The diagnosis and treatment domains, which require the most clinical judgment, had the lowest average domain scores of 53.4% ± 20.9% and 51.6% ± 15.1%, respectively.
Changes in CPV Scores
To determine the impact of serial measurement and feedback, we compared performance in the first two rounds of the project with the last two rounds. We found that overall CPV quality scores showed a 4.8%-point absolute improvement (P < .001; Table 1). We saw improvements in all care domains, and those increases were significant in all but the workup (P = .470); the most significant increase was in diagnostic accuracy (+19.1%; P < .001).
By condition, scores showed similar, statistically significant overall improvements: +4.4%-points for pneumonia/sepsis (P = .001) and +5.5%-points for heart failure (P < .001) driven by increases in the diagnosis and treatment domains. For example, providers increased appropriate identification of HF severity by 21.5%-points (P < .001) and primary diagnosis of pneumonia/sepsis by 3.6%-points (P = .385).
In the treatment domain, which included clinical decisions related to initial management and follow-up care, there were several specific improvements. For HF, we found that performing all the essential treatment elements—prescribing diuretics, ACE inhibitors and beta blockers for appropriate patients—improved by 13.9%-points (P = .038); ordering VTE prophylaxis increased more than threefold, from 16.6% to 51.0% (P < .001; Table 2). For pneumonia/sepsis patients, absolute adherence to all four elements of the 3-hour sepsis bundle improved by 11.7%-points (P = .034). We also saw a decrease in low-value diagnostic workup items for patient cases in which the guidelines suggest they are not needed, such as urinary antigen testing, which declined by 14.6%-points (P = .001) and sputum cultures, which declined 26.4%-points (P = .004). In addition, outlining an evidence-based discharge plan including a follow-up visit, patient education and medication reconciliation improved, especially for pneumonia/sepsis patients by 24.3%-points (P < .001).
Adherence to AdventHealth-preferred, evidence-based empiric antibiotic regimens was only 41.1% at baseline, but by the third round, adherence to preferred antibiotics had increased by 37% (P = .047). In the summer of 2017, after the third round, we updated scoring criteria for the cases to align with new AdventHealth-preferred antibiotic regimens. Not surprisingly, when the new antibiotic regimens were introduced, CPV-measured adherence to the new guidelines then regressed to nearly baseline levels (42.4%) as providers adjusted to the new recommendations. However, by the end of the final round, AdventHealth-preferred antibiotics orders improved by 12%.
Next, we explored whether the improvements seen were due to the best performers getting better, which was not the case. At baseline the bottom-half performers scored 10.7%-points less than top-half performers but, over the course of the study, we found that the bottom half performers had an absolute improvement nearly two times of those in the top half (+5.7%-points vs +2.9%-points; P = .006), indicating that these bottom performers were able to close the gap in quality-of-care provided. In particular, these bottom performers improved the accuracy of their primary diagnosis by 16.7%-points, compared to a 2.0%-point improvement for the top-half performers.
