Another day for a heart surgeon, another coronary artery bypass graft. Can't forget to order the usual two pints of blood. But hold on a minute. Has anyone pointed out the recent evidence that shows one pint is usually enough? That overusing transfused blood can increase infection risk, reduce immune response, extend a hospital stay? Time to rethink, maybe change, the policy on blood usage.

In the emergency department, a Medicare-age man complains to the doctor about his lower-back pain of the last few weeks. This man needs a CT scan, the physician immediately concludes. That would pick up a bulging disk, which surgery could correct. But hold on a minute. Studies have shown that if all people his age had a CT scan, half will show a bulging disc, often not tied to any symptoms. The finding by itself is insufficient reason for a hospital stay, much less back surgery. The upshot: There's little call for the scan here.

Similar unnecessary use of resources, against evidence, can result from hospitalizing for simple pneumonia, doing a brain scan for chronic isolated headache and performing elective cardiac catheterization instead of trying drugs first. These frequently employed treatments and diagnostics add risk to patients and expense. If health care is to survive the transition to value-based, fixed payment, the proliferation of costly care with questionable quality can't go on much longer.

"I think everyone sees the writing on the wall. No matter what the model for the future holds exactly, it's clear that the cost curve cannot continue the way it is," says Ken Sands, M.D., senior vice president for health care quality at Boston's Beth Israel Deaconess Medical Center. "I think everyone acknowledges that, and the health of the nation requires we get health care spending under control so that those resources can be used in other ways."

Scrutiny Is Here

Sands is chair of the American Hospital Association's Committee on Clinical Leadership, which provided guidance for a report on stewardship of the limited and decreasing resources available for patient care. The 20-page summation of this initiative, "Appropriate Use of Medical Resources," makes the case for why some inpatient-oriented tests and procedures should be given a hard look, the reasons why physicians have come to overuse certain tools and treatments without justifiable benefit, and five types of clinical care that the AHA will commit to curtailing in the next few years.

Facing this era of constrained resources and rising costs, "it's really incumbent upon us to use those limited resources much more wisely than we were doing in the past," says John Combes, M.D., AHA senior vice president and chief operating officer of AHA's Center for Healthcare Governance. "The message is, for both patients and practitioners, to consider before doing something: Is the benefit worth the risk, and is this effective and efficient in terms of cost to the overall health care system?"

With the shift to demonstrating value, the pressure on pricing, and a gradual increase in managing medical risk with finite contract income, "We're suddenly looking at things that we were dancing over, we were reluctant to touch, we didn't understand," says Lee Sacks, M.D., member of the AHA's leadership committee and executive vice president and chief medical officer of Advocate Health Care, Downers Grove, Ill.

The starter set of scrutinized services being put forward by the AHA consists of blood management, antibiotic stewardship, appropriate ICU use for the terminally ill, reduction of inpatient admissions for conditions that shouldn't be treated in that setting, and reduction of elective heart catheterizations. But in due time, "We're going to see this kind of scrutiny in virtually everything," Sacks says.

The Utilization-Review Slide

Up until about the mid-1990s, an ingrained resource evaluation process known as utilization review and management was a high priority, says Combes. "Utilization review held sway as the way to control quality, to guarantee that there wasn't overusage and also to look at making sure that people got what they needed."

In 1999, that priority began to be nudged lower by a shift to patient safety, he says, a focus triggered by the Institute of Medicine clarion call, "To Err is Human: Building a Safer Health System." Because of resources diverted to safety — and a growing backlash against utilization-review tactics associated with managed care organizations at that time — utilization management "sort of disappeared for a while," he says. That created a climate for making decisions about safety "which some clinicians thought required more intervention without really considering if this placed the patient more at risk."

Despite crowding out utilization-review criteria, the emphasis during the past decade on patient safety and preventing harm did foster an understanding that all health care procedures and interventions come with some risk. Part of the new push for resource stewardship is to make sure that medical tests and procedures are used judiciously, to minimize risk and maximize benefit, Combes explains.

Another issue in revisiting resource usage is the unsavory reputation that utilization review acquired in the 1990s. People equated managing care with managing cost, says Mark Adams, M.D., chief medical officer of Franciscan Health System, based in Tacoma, Wash. "It made us feel as though we were withholding treatment because of money," he says. What the health care field needed was a new approach that puts quality up front, delivering care such that it has the extra effect of saving money, but that's not the main intent, says Adams, a member of the AHA's leadership committee.

But there's no doubt that curbing costs is part of the equation, Sacks says, and that means getting past the sting of the utilization-review backlash of the past. "Clearly, the pressure on pricing and reimbursement is forcing delivery systems to look critically. What we thought was good utilization in the '80s pales in contrast to where we are now."

'Enamored with Technology'

Technology advancement has improved the life-saving odds for clinicians' fighting serious disease, but dependence on diagnostic testing and consequent inpatient care for procedures has reached the point at which it increases the cost of care when alternative approaches would provide the same benefit for patients but at less expense and risk, Combes says.

Over the years, many interventions have become "a lot more technically feasible and easy to do, and both the profession and patients have become enamored with the technology," with its prospects of "quick fixes" for a problem, he says. One example: performing invasive cardiac procedures for a not-yet-critical narrowing of a coronary artery when a drug could provide the same outcome but over a longer time period. "People will tend to go for the easier intervention, but the problem is that it introduces more risk than taking the drug therapy, and it is much more expensive," Combes says.

"Consumers have a big role in this, too," Adams adds. Patients want the latest test, the latest antibiotic. "Consumers were willing participants" in the decision-making, and there have been few brakes on that demand.

"Under the traditional fee-for-service model, physicians had free rein to order tests, to perform procedures, and there was an incentive to do so in terms of [profiting] financially, but also in terms of patients' perceiving that as good care," says Sands. "All the incentive was in the direction of doing more. And acknowledging that there can be a gray area in terms of when the test is needed or not, it was very easy to go in the direction of overuse."

Improvement in diagnostic tests, to the point that they pick up issues that are incidental rather than material to a patient's condition, has led to pursuing further tests and invasive procedures for an anomaly that either wouldn't have amounted to anything or would not have contributed useful information. There's even an ironic term for that, incidentaloma, a malady characterized by overaggressive clinical reaction to chance detection of a suspicious something on a scan.

Further pulling physicians in the direction of overuse is the maxim "traditionally taught either directly or subtly, that a good clinician is a thorough clinician, who does all potentially useful tests," Sands adds. "The 'no stone unturned' was where a lot of the value and admiration came from when you were a physician in training."

The ultimate result of all these forces is that "every clinician lives in fear of missing a diagnosis, not just for liability reasons but because that's how they define themselves as being a good clinician," he says. "And they traditionally have lived in considerably less fear of overutilization. It wasn't something that directly affected them."

Fewer Resources, More Concern

Those days may be coming to an end, either through the clinicians themselves or laid out for them by managers, fed-up payers and government stewards of taxpayer funds. For medical groups and health systems, payer reactions to rising costs — along with the rising prices of medical supplies — have ushered in an era in which "the resources available are significantly less now," says William Pinsky, M.D., executive vice president and chief academic officer of Ochsner Health System, New Orleans, and another AHA leadership committee member.

Appropriate use of medical resources becomes a natural outgrowth of such concern. Both hospital administrators and physician leaders "basically see this as something important to the viability of their practice setting or wherever they deliver care," says Pinsky, adding, "I frankly think it's always been a responsibility, and we have always talked about it, but we haven't had a systematic way of making this a part of what we do."

The American Board of Internal Medicine took on that systemization, challenging each specialty's medical society to identify five things physicians and patients should question and discuss. The program arising from Choosing Wisely, the ABIM Foundation initiative, aims to reduce frequently ordered tests and procedures, often in favor of alternatives with more evidence of better value and lower risk.

Overwhelming response from the physician community, whose contributions to the list exceed 250 items and continue to grow, "acknowledges that health care has transitioned from fee-for-volume to fee-for-value, that the transition is occurring today and that the trend will continue," says Scott Weingarten, M.D., senior vice president and chief clinical transformation officer at Cedars-Sinai Medical Center, Los Angeles. The guidance of the ABIM signals willingness to go along with that transition and is in part meant to help physicians succeed in this new world of health care, says Weingarten, who has helped to embed clinical decision support at Cedars-Sinai to target more than 100 of the tests and procedures on the scrutiny list.

The AHA campaign kicks off with the same group-of-five approach, with a wrinkle: It emphasizes decisions about what to do and not do in the hospital setting, whereas medical societies have focused largely on the intricacies of evidence for or against clinical practices. The Committee on Clinical Leadership "wanted to make sure we were not preaching to others," says Combes. "We're the American Hospital Association and we were making recommendations back to our own field about this."

The chosen situations "were most strongly affected by the system in which they were delivered," says Elisa Arespacochaga, director of the AHA's Physician Leadership Forum, which includes the leadership committee. "So the hospital has a strong control over these specific five, and could put systems in place to help people understand that they need to consider the options and have a conversation."

Guiding Resource Choices

Identifying possibly inappropriate care choices is one thing; winning over physicians and patients is another. Unlearning the "no stone unturned" approach will be difficult for doctors, but just as medical leadership fostered the previous culture, it can do the same now, Sands says. "If you can get a small minority of the clinical leaders whom others look up to as highly skilled, highly knowledgeable clinicians, and get them to be voicing the change, then others will follow."

Well-informed clinicians have the task of explaining the choices to patients. In the past, clinicians who took on this role generally were on their own as to cogent explanations and materials to share with patients. A key piece of the AHA initiative is to create toolkits with materials to have in hand for the conversation. Each kit will have discussion guides for physicians, information packets for patients and implementation guides for institutions.

The first toolkit, which takes on appropriate blood management in inpatient services and was developed in conjunction with AABB, the professional society for transfusional medicine, will be available in April, Combes says. It deals with how to put together a program that leads to the most appropriate use of blood and blood products, including explanations to patients about getting blood in certain situations [see sidebar, Page 11]. Successive toolkits will be issued approximately each quarter, with the next one likely to be on appropriate antimicrobial stewardship, says Combes.

For Weingarten, who already has seen reductions of 12 to 18 percent almost overnight in tests and treatments targeted in the Choosing Wisely program, educating patients will have a definite impact. "It's amazing how many patients, when given good information, will say, 'Well, after I understand all of the facts, I'm not sure I want that CT scan; let me give it some thought,' when going in to the physician that day, they might have thought they wanted a CT scan."

"None of what we're talking about is cutting the patient out," says Combes, "and, in fact, it's doing just the opposite — it's trying to engage the patient early in the discussion about treatment options and the pluses and minuses of each option. The data suggest that the more the patient is engaged in care decision-making, the more conservative that patient will be in choosing treatment options."

John Morrissey is a freelance writer in Mount Prospect, Ill.

'Counterintuitive' Evidence Reverses Blood Flow

Medical research has quantified the risk of using blood in certain situations, but it often goes against the training and intuition of doctors.

"I was taught that more is better," says Lee Sacks, M.D., Advocate Health Care's chief medical officer, "and if you're going to give blood, you shouldn't give anything less than two units." The Downers Grove, Ill., system several years ago adopted more recent evidence that indicated its facilities were overusing blood. In late 2011, it started an educational program that led to a 44 percent reduction in the use of blood over the past two years.

Franciscan Health System, Tacoma, Wash., initiated a system in which doctors in most cases had to request permission to order blood and justify it in writing, says Mark Adams, M.D., the system's chief medical officer. Use of blood decreased dramatically. In cardiac surgery, for instance, the percentage of transfused patients dropped to 20 percent from 70 percent.

At Beth Israel Deaconess Medical Center in Boston, an electronic health record function weighs orders for blood against a patient's lab values and queries the purpose of the transfusion, says Ken Sands, M.D., senior vice president for health care quality. For example, the blood hematocrit level based on evidence needs to be below a certain threshold for a transfusion to be beneficial.

The computer response is "not a forcing function — it doesn't prevent the clinician from ordering the transfusion," says Sands. The result, nonetheless, has been lower cost of blood use and lower patient exposure to blood products. In dollar terms, the quarterly purchase of blood products decreased 27 percent in two years, to $1.6 million in the fourth quarter of fiscal 2007 compared with $2.2 million in the first quarter of 2006. Clinical outcomes were either unchanged or improved. "There was no downside in terms of people getting the blood products that they needed," he says.

For physicians who order the blood, educational programs hit them with up-to-date information on the latest science of transfusions, "which can be very powerful," Adams says. For example, likening transfusions to organ transplants gets a clinician's attention. "That's risky, and that's really what a blood transfusion is — taking organs from someone else and putting them in you. It's living tissue, and it has the ability to cause your host body to attack it, which can disrupt your system."

Transfusion also lacks some of the beneficial properties previously thought, such as countering anemia in people with heart disease. "Studies show that actually the death rate goes up if you give those people blood," Adams says. "That's totally counterintuitive but, nonetheless, that's what the evidence is."

Advocate brought in an expert on blood usage to first affirm that the system was "using way too much," says Sacks, and then to communicate the issue to physicians. A physician himself, the consultant was credible to the medical staff, sharing evidence and "taking on all those skeptics and resisters to change." Then, physician champions in key areas such as trauma surgery as well as pathologists who ran the blood bank joined the consultant in educating large users of blood, he explains.

"This was not just a cost [issue], because there's good evidence that the more blood products you transfuse, you increase the risk of infection, you decrease immune response, and it leads to other complications," Sacks says. Patients who get transfused have longer hospital stays, more adverse events and a higher cost course.

Between September 2011 and December 2013, Advocate's program registered $8.9 million in savings, which affected more than the bottom line, says Sacks. "That translates into 20 FTEs of nurses; so it either means that we've repurposed them to do other things that are valuable, or it enables us to downsize because we save work." Advocate also computed health outcomes benefits based on scholarly findings about transfusion risk, and came up with 732 complications avoided, 165 lives saved and 24,449 patient days reduced. — J.M.

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Changing patients' expectations about antibiotics, procedures and ICU use will require physician finesse.
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