Over the past two decades, and the past five years in particular, a national discussion has emerged concerning the increased cost of health care. Perhaps of greater importance, higher costs have not always led to improved outcomes. In fact, overdiagnosis, overuse of treatments and a "try everything" approach have contributed to these higher costs with little discernible improvement in health.
Care providers endeavor to provide the most appropriate care to patients regardless of cost, but all too often there isn't enough discussion with patients about what is appropriate. How can the health care system equip patients to participate in those discussions and make the most informed decision in partnership with their caregivers? As medical societies, provider organizations and others look for ways to encourage appropriate use, hospitals and health systems can play an important role in supporting and guiding these efforts.
The American Hospital Association, with guidance from its Committee on Clinical Leadership, examined the issue and developed the white paper "Appropriate Use of Medical Resources" that identifies the drivers of health care utilization and recommends a way to reduce non-beneficial services and to improve care. Among its efforts, the AHA 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, including:
- appropriate blood management in inpatient services
- appropriate antimicrobial stewardship
- reducing inpatient admissions for ambulatory-sensitive conditions (e.g., low back pain, asthma, uncomplicated pneumonia)
- appropriate use of elective percutaneous coronary intervention;
- appropriate use of the intensive care unit for imminently terminal illness (including encouraging early intervention and discussion about priorities for medical care in the context of progressive disease)
To further support hospitals' efforts, the AHA's Physician Leadership Forum is producing toolkits on each of the list's five practices. To date, it has released toolkits on patient blood management, antimicrobial stewardship and ambulatory care-sensitive conditions. To access any of the previous toolkits, click here. The most recent toolkit addresses the appropriate use of elective percutaneous coronary intervention, or PCI, for patients with acute heart disease.
Elective PCI for patients with acute heart disease is one of the most common procedures performed in the United States — more than half a million a year, according to a 2011 Journal of the American Medical Association article. Roughly a third of the procedures were performed on people with mild or non-acute symptoms. Of those, the JAMA article found almost 12 percent to be medically unnecessary. The procedure is not just common, it is also costly. A 2011 Wall Street Journal article pegs the average cost of the procedure at $20,000.
According to the American College of Cardiology, the 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, or STEMI). Research has shown, though, for patients with non-acute coronary artery disease, PCI can have little to no effect on outcomes. The American College of Cardiology Foundation, in partnership with others, released revised guidelines outlining standards for cardiac catheterization in 2012.
To bring more awareness to this issue, the Physician Leadership Forum collaborated with ACC, the American Heart Association and SCAI to provide hospitals and health systems with resources and tools to help in their quest for safe, high-quality care. The toolkit is broken down into three sections:
- Hospital and health system resources: includes quality improvement resources and links to the National Cardiovascular Data Registry®
- Clinician resources: includes mobile applications, guidelines and clinical evidence supporting the appropriate use of elective percutaneous coronary interventions
- Patient resources: includes resources to understand the best use of angioplasty and how to obtain the right tests and treatments
Highlights include the American Heart Association's Get With The Guidelines® suite of hospital-based quality improvement programs and registries that help hospitals to follow the most up-to-date, research-based treatment guidelines; reduce gaps and disparities; and support registries for cardiovascular research. In addition, participation in the CathPCI Registry®, developed by ACC with SCAI providing support, captures the data that measure adherence to ACC/American Heart Association clinical practice guideline recommendations, procedure performance standards and appropriate use criteria for coronary revascularization. Also included in the toolkit is SCAI's online risk calculator that allows clinicians to determine the appropriate use score for individual PCI procedures based on individual patient clinical characteristics.
Appropriate use of PCI with the right patient at the right time can improve outcomes, reduce hospital admissions and readmissions, and lower costs. By reducing the utilization of non-beneficial care — care that increases costs without a concomitant increase in value — health care can move closer toward achieving the Triple Aim of improving the patient experience of care (including quality and satisfaction), improving the health of populations and reducing per capita costs.
John R. Combes, M.D., is the chief medical officer and a senior vice president of the American Hospital Association. He is also the president of the Center for Healthcare Governance, an AHA affiliate, and is a member of Speakers Express.