Comparative data sells physicians on care paths
They see costs drop and care improve
When cardiologists at Vanderbilt University Medical Center in Nashville, TN, expressed interest in revising some critical paths, Karen Elder, RN, MSN, coordinator of case management practices, was ready with a plan. Her team began the pathway-building process by deciding what a reasonable length of stay (LOS) should be for acute MI or unstable angina, and what the daily goals should be to get patients discharged within the target LOS.
"We compared this with our local competition’s LOS for the same DRGs," Elder says. "Then we decided what resources we would need to meet those goals the medicine, the treatments, the X-rays. Then we asked what it would cost and if there was a less expensive medication or test we could use and still obtain the same result."
She says sometimes "stalemates" occurred where physicians and other team members couldn’t agree on a portion of the pathway. In that situation, Elder explains that the team then would return to its original goal.
"We would go back first of all to the vision we had for the program," she says. "We want to be one of the best programs in the country. To do that, we have to be cost-efficient and deliver high-quality care."
Also as part of the process, the team would look at what "opportunities for change" were available to them. Costs for some lab tests, for example, simply can’t be reduced, but how the tests are ordered can be changed. For example, cardiac enzyme testing (creatine kinase muscle brain, or CKMB) to rule out MI is supposed to be done eight hours apart three times. The test costs about $50.
"But sometimes, they’re ordered five times or even more," Elder says.
Oxygen use expensive
Another example of cost-cutting is oxygen administration. Elder says physicians sometimes forget to discontinue oxygen when patients no longer require it, or when a patient has an oxygen saturation rate of 98%.
"That oxygen on the wall is costing $80 every eight hours," she says. "Every three days, there’s an additional cost of $50 for [oxygen] tubing and a bottle of water. That is a minimum cost of $240 a day."
During the first year of the pilot program, charges did decrease for Vanderbilt’s cardiology division overall. There was a savings of $652,000 and $643,000 of that came from savings generated by the four physicians who participated in the pilot on ischemic heart disease.
Elder says since 1992, many pathways have been developed at the hospital involving urologists, neurologists, orthopedic surgeons, and other specialists.
"We’ve used the same principles across all service lines," she says.
The biggest selling points she found in getting physicians involved was providing them with data, which helped remind them that they can’t afford not to be competitive in today’s health care market.
"We tried to always frame things in terms of how this [information] would affect them personally," says Elder, "how this could improve their practice, the care they delivered to patients, and their own personal reimbursement."
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