The Appropriate Use of Medical Resources white paper identifies some of the drivers of health care utilization and its contributing factors. More importantly, the paper recommends a way to move forward that will place hospitals at the forefront of innovative change for reducing non-beneficial services while improving health care overall. Among our efforts, we have developed a “top five” list of hospital-based procedures or interventions that should be reviewed and discussed by a patient and physician prior to proceeding.
This paper builds on the Ensuring a Healthier Tomorrow report which identified two interconnected strategies to improve care while achieving a sustainable level of health care spending: promote and reward accountability, and use limited health care dollars wisely. As an outgrowth of the latter, the AHA, with guidance from its Committee on Clinical Leadership, Physician Leadership Forum, regional policy boards and governing councils and committees, closely examined the appropriate use of medical resources.
To begin the discussion in your hospital and community, share Appropriate Use of Medical Resources with your board, medical staff, and community leaders and use the accompanying discussion guide to explore the issue together. In the coming months, the AHA will roll out resources targeting each of the five procedures or interventions. We also will share best practices from hospitals and health systems that are already on this path. If your organization is well on the path to adopting one, please share your story with us.
The most appropriate use of the ICU can improve outcomes, improve the care experience and lower costs. Hospital and health care systems should encourage early intervention and discussion about priorities for medical care in the context of progressive disease and robust communication between patients and their providers to understand patients’ preferences and goals. These discussions should address the likelihood of acceptable (to the patient) recovery, the risk of long-term impairment or death, the options for palliative care co-management at the same time as disease-directed treatment and the benefits of hospice care, all in the framework of the patient’s priorities.
According to the American College of Cardiology, American Heart Association, the Society for Cardiovascular Angiography and Interventions and other experts, immediate coronary angiography with PCI is recommended for patients with ST elevation myocardial infarction (STEMI). Research has shown, though, for patients with non-acute coronary artery disease, PCI has little to no effect on outcomes. Appropriate use of PCI with the right patient at the right time can improve outcomes, reduce hospital admissions and readmissions and lower costs.
As resource-intensive settings, emergency department and inpatient hospital care need to be carefully monitored to ensure the most appropriate use. Significant research has shown that for several Ambulatory Care Sensitive Conditions (ACSCs) access to primary care, urgent care clinics, outpatient services, and other sub-acute settings can improve patient outcomes, reduce hospital admissions and readmissions, and lower costs.
Reducing ACSC admissions requires understanding of the problem and a commitment to making change. Factors contributing to the high cost and low value of ACSCs include the shortage of primary care physicians, ineffective communication between primary care and subspecialist physicians and a lack of patient engagement. This toolkit includes resources that can begin to address these barriers. In addition, the toolkit features case examples of best practices, evidence from the field of effective initiatives to address specific ACSCs such as pediatric asthma.
Antibiotics are one of the great discoveries in medicine and the most important weapon in fighting bacterial diseases. Infections that were once deadly can now be cured, and antibiotics have made many life-saving treatments possible. However, when it comes to antibiotics, more is not always better.
Overuse of antibiotics has garnered national attention with stories of deaths due to antibiotic-resistant strains of bacteria. Unfortunately, unnecessary use of antibiotics not only leads to public health concerns from resistant strains, it also can cause serious side effects. The CDC reports that approximately half of all antibiotic prescriptions written in the United States are either unnecessary or used inappropriately. Ear infections, for example, are often overtreated with antibiotics when watchful waiting would suffice. Antibiotics also are often inappropriately used to treat viral conditions for which they have no effect.
In 2012, SHEA, IDSA and PIDS issued a policy statement calling for the development and broad dissemination of antimicrobial stewardship programs (ASPs) stating that “antimicrobial stewardship must be a fiduciary responsibility for all health care institutions across the continuum of care.” Antimicrobial stewardship programs, defined by SHEA as “coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy and route of administration,” have increased in hospitals and health care systems in recent years, but more must be done.
To be effective, ASPs need to engage patients, providers and administrators to work together to appropriately use antibiotics. A comprehensive, multidisciplinary effort across the hospital or health system provides the structure needed to ensure antibiotic use is carefully monitored. Core elements for implementing an ASP, as identified by the CDC and included as a resource in the toolkit, include:
- Leadership: Leadership must make a firm commitment to creating and running an antibiotic stewardship program, including making sure all necessary resources are in place and support and education are offered.
- Accountability: Identify a single leader, preferably a clinician with training in infectious diseases and committed to quality improvement, who will be responsible for all outcomes. This person should have the support of and be able to work across all hospital groups.
- Drug expertise: Identify a pharmacy leader who will help co-lead the program.
- Optimal antibiotic use: Pick interventions based on the needs of the facility. Do not try to implement too many changes at once. Interventions can be broad in nature, such as antibiotic “time outs” or making sure one has prior authorization, or they can be more specifically focused on certain conditions.
- Track antibiotic patterns: It is important to measure whether antibiotic processes and policy, their use and the outcomes associated with such use, are working.
- Report: On a regular basis, make sure all staff are aware of antibiotic use and resistance. Also, if possible, link your hospital with the CDC’s Antibiotic Use Option, which reports monthly outcomes.
- Education: Employ a variety of educational resources, including didactic presentations, messaging and web-based resources.
By implementing an ASP, hospitals can ensure antimicrobial efficacy and safety for their patients. These programs help ensure patients receive the right antibiotics at the right time and for the right duration. An effective ASP should reduce costs, but more importantly, appropriate antimicrobial use saves lives.
The AHA collaborated with the following organizations to develop the antimicrobial stewardship toolkit:
- Association for Professionals in Infection Control and Epidemiology (APIC)
- American Society of Health-System Pharmacists (ASHP)
- Centers for Disease Control and Prevention (CDC)
- Infectious Diseases Society of America (IDSA)
- Pediatric Infectious Diseases Society (PIDS)
- Society for Healthcare Epidemiology of America (SHEA)
- Society of Hospital Medicine (SHM)
Clinical research has shown that restrictive transfusion practices are generally associated with better patient outcomes as well as reduced health care resource utilization. This evidence has emerged as providers are increasingly being urged to implement evidence-based clinical decision guidelines that improve the quality and efficiency of the care they deliver and measure patient outcomes. In light of these health care landscape changes, increased attention has been placed on the clinical decision to transfuse blood products.
A growing number of clinicians who order blood products are turning to patient blood management (PBM) as an important component of their care planning decisions. PBM comprises a variety of methods, such as the use of evidence-based transfusion guidelines as well as anemia and coagulation management.
A general strategy for initiating a PBM program includes:
- Commitment from hospital leadership to support the development and implementation of the program.
- Development of a preoperative anemia management program.
- Utilization of intraoperative strategies such as blood recovery, normovolemic hemodilution and component sequestration.
- Implementation of point-of-care monitoring in the OR and ICU environments.
- Establishment of an auditing mechanism to ensure reasonable blood utilization.
An evidence-based approach to blood utilization leading to blood usage reductions has the potential to substantially lower facility expenditures and improve patient outcomes, allowing those resources to be redirected to other areas of need within the hospital.
A great deal of work still remains to reduce the number of unnecessary transfusions in the U.S. To accelerate progress, an expanding number of major medical societies are making the appropriate use of blood an important area of focus.
Many hospitals in the U.S. have already embraced PBM and positive patient outcomes have resulted along with a reduction in the variation of practice within the institutions. A comprehensive PBM program has been shown to be a valuable tool to hospitals, hospital systems and clinicians as they strive to improve outcomes while lowering cost.
AHA Town Hall Webcast
AHA President and CEO Rich Umbdenstock hosts several guest speakers to discuss the Appropriate Use of Medical Resources report, as well as the toolkits the AHA’s Physician Leadership Forum will be releasing for each of the five areas. The first two toolkits, Patient Blood Management and Antimicrobial Stewardship, are highlighted during the program.
Featured speakers include:
- Elisa Arespacochaga – director, Physician Leadership Forum, American Hospital Association
- Miriam A. Markowitz – chief executive officer, AABB
- Kenneth E. Sands, MD – chief quality officer and senior vice president of health care quality and safety, Beth Israel Deaconess Medical Center