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Results From Ambulatory High Value Care Committee

Cedars-Sinai excels at providing high-quality care. But more isn't always better. Sometimes—with the best of intentions—tests are ordered and medications are prescribed that aren't necessary and may even be harmful. This wastes patients' time and money, and exposes them to needless risk.

The Cedars-Sinai Medical Network is committed to providing high-value care to our patients, guided by the latest medical evidence. That means delivering care in a manner that is efficient, safe and affordable.

In an effort to achieve this goal, a diverse group of physicians and executive leaders launched the Ambulatory High Value Care Committee. These leaders worked with key clinicians and engaged in thoughtful redesign to leverage guidelines from Choosing Wisely—a national initiative to reduce healthcare utilization where harm or expense outweighs benefit to the patient—to make progress in five specialties: cardiology, gastroenterology, oncology, pain management and preoperative evaluations. Promising results from their small pilot projects suggest much greater returns for the broader Medical Network going forward. Accomplishments in FY18 included the following:

Cardiology

  • Goal: Decrease inappropriate cardiac stress testing
    Why is this important? For many patients, cardiac stress testing rarely changes a treatment plan or outcomes but does cause excess radiation exposure and unnecessary expense.
    What were the results? Cardiac imaging orders decreased by 2.5 percent in FY18 compared to previous year, saving $106,000.
  • Goal: Decrease inappropriate lab testing
    Why is this important? The most common medical activity, lab testing often drives clinical decision-making. However, in many circumstances it may not change treatment and can result in low-value care.
    What were the results? Lab orders for specific tests frequently ordered by cardiologists decreased by 37 percent in FY18 compared to previous year, saving almost $42,000.

Gastroenterology

  • Goal: Decrease unnecessary colonoscopies by recommending that normal-risk patients wait 10 years before undergoing a follow-up colonoscopy after normal findings
    Why is this important? Every procedure has risk, and unnecessary procedures increase these risks along with costs. Guidelines from the U.S Preventive Services Task Force and the American College of Gastroenterology recommend waiting 10 years for a follow-up colonoscopy after normal findings.
    What were the results? Increased physician adherence to following guidelines and recommending an appropriate 10-year interval colonoscopy screening to 92 percent of patients, representing a 19 percent improvement over the previous year.

Oncology

  • Goal: Increase the number of referrals to Supportive Care Medicine (palliative care) for patients with metastatic cancer
    Why is this important? Early consultation with palliative care not only leads to greater longevity and better quality of life, but resulting patient care also tends to be less costly.
    What were the results? Increased referrals to Supportive Care Medicine by 55.4 percent in the first half of 2018 compared with the previous six months. In addition to giving more patients earlier access to this valuable service, these additional referrals will potentially generate up to $288,000 in healthcare cost savings in the care of these patients during the last three months of their life, according to a 2016 study published in the Journal of Palliative Medicine.
  • Goal: Reduce unnecessary imaging for breast cancer patients at low risk of metastasis
    Why is this important? High-cost imaging is commonly overused in early-stage breast cancer patients whose cancer is unlikely to spread. This exposes patients to unnecessary radiation, expense and worry due to incidental findings.
    What were the results? Could not quantify due to lack of a reliable data source on cancer staging.

Pain Management

  • Goal: Increase the number of “pain contracts” with patients who were part of a pilot program for chronic opioid therapy
    Why is this important? Aligning treatment goals and establishing shared expectations between physicians and patients help to build trust, reduce opioid requirements over time and make opioid-related complications (and subsequent healthcare utilization) less likely.
    What were the results? Increased number of contracts signed during first half of 2018 amongst the pilot patients so that 85.5 percent of eligible patients on opioids had contracts in place.
  • Goal: Increase enrollment in one of several assistance programs for patients taking both opioids and benzodiazepines (sedative hypnotics)
    Why is this important? This drug combination has been linked to increased risk of ED visits, hospitalization and death.
    What were the results? New assistance programs enrolled 30 patients during first half of 2018, and an additional 27 patients discontinued medications.

Preoperative Evaluations

  • Goal: Reduce preoperative chest X-rays for patients with no history of cardiac or pulmonary disease
    Why is this important? Unnecessary chest X-rays expose patients to radiation, increase costs and are unlikely to change treatment.
    What were the results? Reduced chest X-ray orders by 18.5 percent during third quarter of FY18 compared to FY17 quarterly average. When annualized, the reduction in orders translates to $3,745 in estimated cost savings.