Twenty years ago, Reuland says, "we thought that if we as providers had an intervention that could possibly help someone, then giving patients access to it was a good thing. I think a generation later, we're learning that turning off our medical apparatus is as important sometimes as turning it on."
Saving money and avoiding harm
One such project to pare costs and avoid harm is the brainchild of Jeffrey Trost, MD, 43, director of Bayview's cardiac catheterization laboratory and deputy director for clinical practice.
Trost made a persuasive case to almost completely eliminate redundant and less accurate cardiac enzyme blood draws—tests that added costs to hospital expenses and patients' bills—when the troponin enzyme test did a much better job at detecting blockage of blood supply to heart muscle.
Trost says as he was starting out in the cath lab, he'd see people referred for procedures who'd had "double-digit" quantities of creatine kinase (CK) or creatine kinase–myocardial band (CK-MB) cardiac enzyme blood tests, when two or three would have sufficed.
"It struck me as wasteful and wrong," he says. "Imagine if you as a patient knew that your doctor ordered 10 or 11 tests when two or three would do—and either you or your insurance company is going to pay for it; we all wind up paying for it somehow."
So many blood draws can cause harm, he says. "In theory and in practice, by reducing the number of cardiac tests ordered, we reduced potential harm by reducing unnecessary blood draws and, more important, reduced the number of downstream tests, such as stress tests and invasive cardiac procedures that would be prompted by abnormal results."
With support from leadership, Trost and colleagues created and distributed an evidence-based guideline with "suggestions" physicians could use when ordering these tests.
Over the next 12 months, they found a 66% reduction in cardiac enzyme tests compared with the prior 30 months, and no missed diagnoses.
Although actual cost-reduction estimates are difficult because of Maryland's unique prospective payment system, hospital charges to payers dropped by $1.2 million, Trost says.
Oral versus intravenous drugs
Across the country at 722-bed University of California San Francisco Medical Center, hospitalist Christopher Moriates, MD, just one year out of residency, has launched the High Value Care Committee and has reduced spending and potential harm in at least six ways.