Fine-tuned stroke regs save $865 per patient
Formula involves adherence to a gold standard
Clinicians at the North Mississippi Medical Center in Tupelo have discovered that by streamlining their care of stroke patients they are able to realize significant cost savings and save lives, as well.1 In 1995, the medical center was treating 356 ischemic stroke patients at an average cost of $7,111 per patient. Average length of stay (LOS) then was 9.9 days, and the mortality rate was 11%. After some changes were made including the addition of a stroke nurse case manager, only 26 of 399 treated patients died, lowering the mortality rate to 6.5%. The average LOS decreased to just over a week - 7.2 days - and the average nonadjusted cost per patient dropped by more than 12% to $6,246.
In addition to such factors as decreased LOS, the facility saved money by avoiding common complications of stroke such as aspiration pneumonia, urinary tract infections, and decubitus ulcers. (See article on avoiding aspiration pneumonia, p. 102.) "Any complications drive up your cost of care and delay patients' progress," warns Jan Englert, RN, director of the clinical efficiency department at North Mississippi.
"We've found that when we improve quality, cost issues automatically follow," she says. "It's the [W. Edwards] Deming principle that if you reduce variation, you improve quality, and decreased costs follow." (See the Deming Institute Web site for more information: http://deming.org.)
In 1994, North Mississippi's peer review organization, the Mississippi Foundation for Medical Care, did a chart review of the facility's work using basic, predetermined criteria - CT scan, emergent hypertension treatment, deep vein thrombosis prophylaxis, etiologic evaluation, and stroke prevention therapy. "That review became our springboard for improving stroke care here and implementing the Stroke Initiative Task Force," says Anita Box, RN, stroke case manager for North Mississippi.
In 1993, the 647-bed tertiary care facility lost more than $1 million on stroke patients. The state of Mississippi is at the center of the "Stroke Belt," a section of the Southeast with the highest incidence of stroke-related deaths in the country, and the facility accepts referrals from an integrated rural system that serves a 22-county multistate region. It receives an average of 400 cases per year. Ischemic stroke was the medical center's most financially draining diagnosis. Clearly the motivation was there for improving stroke management, and a multidisciplinary Stroke Initiative Task Force was initiated in 1995. Its primary goal was to improve care by increasing adherence to nationally accepted guidelines.
"We took the American Heart Association guidelines and developed protocols with our own physicians," says Englert. "We provided physicians with that gold standard and compared it to their outcomes. We said, 'This is what the AHA and our experts say you should do, and this is what you are doing.' " The feedback caused physicians to look at the variation between how they practiced and what the guidelines suggested.
The task force made its project physician-friendly and encouraged input from doctors.
"Our physicians were very much involved in this project. They said, 'Within three days we're going to try to have the etiology of the stroke determined, and by then we'll be talking to the patient and family about the plan of care for the future.' " That, they said, was the time to evaluate whether the patients would go back with the family or to a nursing home. "The project caused a whole mindset change for a group of physicians in a small town who were used to an environment of physician-initiated consults," Englert says.
"Physicians are getting used to looking at their performance now," she says. "We've been measuring performance on athletes and every other profession. We all have parameters we have to meet. Physicians are late coming to this game. They haven't had their touchdowns counted publicly until recently." She says that North Mississippi wants its physicians to realize their value is based on the quality of their work, and that quality will reduce costs. "No physician here comes to work wanting to do a bad job," says Englert.
The task force didn't encounter much resistance from the physicians. "That's because they're involved, committed, and competitive," both clinicians say. "Because I'm a clinical nurse, not from administration," says Box, "I have an understanding of disease processes and what they do. We have some credibility and they respect that. Physicians don't resist once they realize this is not just a cost issue, but an issue that influences quality of care. Once they realize it will help them do the right thing the first time and not waste resources, they want to cooperate."
Reference
1. Newell SD, Englert J, Box A, et al. Clinical efficiency tools improve stroke management in a rural southern health system. Stroke 1998;29:1092-1098.
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