Medical Staff Pulse Newsletter

Spreading High-Value Care

When new clinical guidelines for preoperative testing rolled out across the health system this year, it was part of a larger effort by a team of clinician leaders at Cedars-Sinai focused on reducing unnecessary care that wastes patients' time and money, and exposes them to needless risk.

Led by the Ambulatory High-Value Care Committee, a diverse group of physicians and executive leaders, these efforts have proved so successful that some goals for the current fiscal year are based on the committee's prior work in specialties such as oncology and preoperative testing.

"Our entire focus is on promoting resource stewardship and creating a culture at Cedars-Sinai that practices evidence-based medicine," said Bradley Rosen, MD, vice president of Physician Alignment and Care Transitions, and co-chair of the Ambulatory High-Value Care Committee with Karyn Eilber, MD. "The key word is 'value.' We always want patients to receive the best possible care, which sometimes means undergoing a more extensive work-up, but in many cases the situation warrants less testing and fewer interventions. The best clinicians in the country know the difference."

The Ambulatory High-Value Care Committee works with key clinicians in particular specialty areas to translate guidelines from professional medical societies and Choosing Wisely into everyday practice.

During the past fiscal year, they focused on four areas: cardiology, gynecology, oncology and preoperative evaluations. Their success with several pilot projects in FY18 suggests the potential for greater returns going forward.

A new focus area this past year was a collaboration between gynecology and primary care. This team identified an opportunity to use more cost-effective intrauterine devices (IUDs). They found that most IUDs implanted in Medical Network patients in 2018 were a brand that's almost twice as expensive as a nearly identical and equally effective alternative. The less expensive IUD could reduce $200,000 in costs annually with no effect on patient care. This group ran a pilot and was able to increase the number of cost-effective IUDs used from 4% in the first quarter of FY19 to 37% in the first quarter of FY20.

"The challenge is that physicians are creatures of habit," Eilber said. "But if we make the case to our doctors and make it easy for them to do the right thing, we have seen that they will embrace the new approach and run with it."

The gynecology and primary care group also worked to reduce unnecessary screening for cervical cancer. Evidence has shown that patients who have normal Pap smear results need less frequent screening, and over-screening could result in harm. Cedars-Sinai was over-screening 11.46% of these patients in CY17, and a pilot program resulted in a reduction to 9.36% in CY18. The group also created patient education brochures and digital monitor signage for OB-GYN waiting rooms.

The other three specialty groups, cardiology, oncology and preoperative testing, built upon their successes from FY18.

The cardiology group had developed computer alerts embedded in electronic health records to flag when cardiac imaging or lab orders might not be necessary. This year, they rolled out these best practice alerts to faculty physicians while working to maintain low rates of inappropriate ordering in the Medical Network. Alerts for cardiac imaging orders by both physician groups decreased by 8% in FY19 compared to FY18, while alerts for lab orders decreased by 100% during the same time period.

The oncology group aimed to improve early intervention by Supportive Care Medicine for oncology patients with metastatic cancers and solid tumors. Studies have shown that getting this care earlier can lead to improvements in a patient's quality of life, treatment decision-making, healthcare utilization, advance care planning, patient satisfaction and end-of-life care. This work led to an increase in advance care planning for these patients from 46% to 52% in FY19 compared to FY18.

The preoperative group rolled out the best-practice guidelines across the health system, including to Cedars-Sinai Marina del Rey Hospital, and monitored adherence. They maintained the FY18 quarterly average of 89 preoperative chest X-rays for patients with no history of cardiac or pulmonary disease. They also reduced "type and screen" orders by 15% compared to FY18 to a quarterly average of 302. This work saved an estimated $380,012 in avoided unnecessary testing before 993 low-risk procedures in the Medical Network in FY19 that were tracked to demonstrate impact.

In FY20, the Ambulatory High-Value Care Committee will build on previous successes while examining new opportunities in different specialty areas.