"It was just a labor intensive process, and we thought we should standardize some protocols and save some time for the patients and physicians by having the nurses manage this at a clinic," explains Ulrich. At first physicians were not in favor of the shift. With approximately 6,600 patients needing this type of care, Ulrich worked to help the providers understand how this project freed up their time and allowed the patients to get more personalized, good quality attention in a shorter period of time. Marshfield Clinic now has several of these "Coumadin clinics" open, and they are finding that their patient outcomes are better, as is patient satisfaction. Once the clinic was off the ground, the data took it in a second direction.
Marshfield began to analyze the effectiveness of two specific blood thinners for its patients: Lovenox and Coumadin. Lovenox is given intravenously for short durations and is more expensive than Coumadin, an oral drug that is generally used for longer periods. Through data analysis, the hospital was able to chart the outcomes of keeping patients on Lovenox for varying time periods, both before and after surgery, thereby enabling it to guide physicians as to the clinically appropriate length of time necessary for patients to stay on Lovenox before transitioning to Coumadin. In the end, that meant patients needed less time on Lovenox, saving the hospital money yet maintaining a high level of patient care.
Cost versus quality
Quality of care is often tossed up as the antithesis of comparative effectiveness, yet many industry leaders believe that quality can improve simultaneously with cost if comparative effectiveness is implemented correctly.
"For those of us who are tasked with bringing effective care to patients, you have to look at things from a quality and cost perspective," says Ulrich. "If we have wonderful treatment but it's too expensive, what good is it? And if we have an affordable treatment that doesn't do enough, then we're in the same place. You have to look for high-quality care at an affordable price."
The improvement in patient care is what is also likely to appeal to third-party payers in the coming years as more and more facilities try their hand at using their in-house data to help guide patient treatment and ultimately decrease costs.
"Many of the large payers already employ analytics and effectiveness analyses to decide what they are going to reimburse, what services they authorize and cover for their enrollees," notes Peggy Naas, MD, vice president of physician strategies for VHA, Inc., an Irving, TX-based national network of not-for-profit hospitals that works to improve their clinical and economic performance.
Naas, who is a board-certified orthopedic surgeon and a former nurse, says she can see both the clinical and administrative advantages for this undertaking. "The kind of data that's needed may be hard to gather but is very meaningful, and it will provide opportunities for hospitals with payers," she says.
Bauer agrees: "I firmly believe that the marketplace is really tiring with the variable quality of healthcare. I think every hospital has to have a mission statement which says: ‘doing it right all the time as inexpensively as possible.'"
Realistically, Bauer says, hospitals can't do this on their own, and for a comparative effectiveness program to succeed over the long haul, providers need to have third-party payers provide incentives. "It's going to be a challenge for them to figure this out."
"I think one of the best possible outcomes that could come from this would be a nimble healthcare system that can generate continual learning, and the value of those learning could be used in such a way that they can deliver improved outcomes," says Naas.
However, there is some concern among healthcare leaders that the benefits of all this data gathering may be lost if the government centralizes the data and creates lists of the most clinically and cost-effective drugs and devices. The worry is that the patient diversity in each region may skew the accuracy of a broad-based central database, and thereby diminish some of the quality gains that occur from hospitals using their own data or data taken from similar hospitals with similar demographics.
"Comparative effectiveness increases the opportunity for observational research and the outcomes that are taking place with certain patient populations," notes Naas.
With so many hospitals giving top priority to quality and improved patient satisfaction, and at the same time focusing on cost control, comparative effectiveness may be the next evolution in healthcare—with or without governmental encouragement and funding. As more hospitals bring their EHRs online in the coming years, it's likely that gathering comparative effectiveness data will become more prevalent and, in time, help drive down costs.