Editor's note: This is the first installment in a two-part series on appropriate use of medical resources. Part 1 identifies five areas where hospitals, in partnership with their clinical staff and patients, should look to reduce non-beneficial care. It also describes the first in a series of toolkits targeting each of the five areas. Part 2 will describe a second toolkit.
While overall growth in health care spending has moderated in recent years, costs are expected to rise due to changing demographics, the growth in chronic illness, advances in medical technologies and the structure of our health care system. The American Hospital Association Board of Trustees, with input from AHA's governance and policy development groups, looked for ways to slow health care spending. That work resulted in Ensuring a Healthier Tomorrow, an initiative aimed at strengthening the nation's health care system and finances.
Health care spending remains a huge target for policymakers in Washington. Through Ensuring a Healthier Tomorrow, the AHA proposed two interconnected strategies that not only will help our health care system to create better clinical and financial outcomes, but also will ensure the financial viability of Medicare and Medicaid, help to reduce federal spending, and tackle the debt:
- Promote and reward accountability, which includes accelerating payment and delivery system reforms, and eliminating preventable infections and complications.
- Use limited resources wisely, which includes eliminating non-value-added treatments and revamping care for vulnerable populations.
Over the past two decades there has been increasing scrutiny of the affordability of medical care, causing clinicians and policymakers to consider whether some medical services are being used appropriately to improve health outcomes or if other factors are behind their use. Overdiagnosis, overuse of treatments due to financial and litigation incentives, a desire to "try everything," and the increasingly information-driven world we live in all have pushed the overuse of medical resources beyond our capacity.
As we transform the health care delivery system, all participants need to ensure that the finite resources in health care are used to improve the quality of care and provide the greatest benefit to patients.
When More Isn't Better
Improved imaging and testing are increasing the diagnosis of disease, but also the potential for harm from unnecessary treatment. For example, the incidence of several cancer diagnoses has increased with no corresponding drop in mortality rates. More people are living with a cancer diagnosis but, more importantly, they are receiving treatments that may not prolong their survival and could reduce their quality of life.
While the overdiagnosis of cancer has garnered much attention due to the invasive and debilitating effects of unnecessary treatments, efforts are underway to curb unneeded care for many other conditions. For example, the overuse of antibiotics, blood and blood products, percutaneous coronary intervention, and scanning technologies all can lead to higher costs and harm to patients. While there is a need to curb overuse, we must focus our efforts on reducing low-value treatments while ensuring that high-value interventions with strong clinical evidence are broadly adopted.
For their part, hospitals and health systems have a responsibility to support only the appropriate and effective use of health care resources. They also have a responsibility to assist providers with tools to better communicate with each other and their patients about appropriate care.
Several studies have highlighted the value of patient engagement and shared decision-making in reducing non-beneficial care and reducing costs. Provider education about the most appropriate use of medical resources is becoming more prevalent. Such education is being led by the work of medical specialty societies in the development and dissemination of evidence-based guidelines, and by hospitals and health systems that are encouraging their adoption and use by practitioners.
Hospital Top Five
As part of its work, the AHA's Committee on Clinical Leadership, a policy advisory group of clinicians, developed "Appropriate Use of Medical Resources," a white paper released in November 2013 that identifies five areas in which hospitals, in partnership with their clinical staff and patients, should look to reduce non-beneficial care. The paper also suggests ways hospitals and the AHA can play a role in addressing the appropriate use of medical resources.
The five hospital-based procedures or interventions that patients and physicians should discuss prior to proceeding are as follows:
- appropriate blood management in inpatient services;
- appropriate antimicrobial stewardship;
- reducing inpatient admissions for ambulatory-sensitive conditions (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).
The white paper also includes a guide for hospitals and their communities to discuss the need to reduce non-beneficial care. To help hospitals and their communities address the five procedures or interventions, the AHA will release toolkits throughout the year targeting each of the five points. Each toolkit contains:
- a user guide explaining the resources and how to use them, with whom in the organization to share them, and how hospitals can begin addressing the issue;
- a readiness-assessment tool to judge the ability of all parties to address appropriate care;
- resources for hospitals and health systems, including articles, case examples and frequently asked questions;
- resources for clinicians, including clinical evidence supporting appropriate use, such educational resources as videos, webinars and clinical practice guidelines;
- tools for patients, including a guide on how to engage in their care, frequently asked questions and questions to ask providers.
Patient Blood Management
The AHA released its first toolkit in April 2014 on appropriate blood management in inpatient services. Transfusing blood when it's not indicated is associated with a number of complications, such as increased length of stay, allergic reactions, organ failure and even death. Studies show that proper management of blood and blood products saves lives and reduces harmful complications. In addition, as the cost of blood continues to rise while the number of donors continues to fall, reducing the number of transfusions not only will alleviate the shortage of blood, but also will rein in costs.
Developed with resources from AABB, an international, nonprofit association representing individuals and institutions involved in transfusion medicine and cellular therapies, the patient blood management toolkit contains a number of resources to help hospitals, clinicians and patients, including:
- an online assessment tool that hospitals and their clinicians can use to pinpoint their readiness for adopting a formal PBM program; it directs them to resources to begin the work;
- a webinar aimed at clinicians that includes data and compelling evidence for the use of PBM to improve care and lower costs;
- an iPhone app from the AABB that includes three valuable PBM resources — a red blood cell transfusion data card, blood transfusion therapy data card and information for the use of human blood and blood components;
- numerous articles and guidelines highlighting the clinical evidence and supporting the use of PBM programs.
The five areas of non-beneficial care identified in "Appropriate Use of Medical Resources," along with such efforts as patient blood management, are a great start. But to achieve the Triple Aim of better health, better health care and reduced costs, we need to engage all stakeholders in using medical resources appropriately.
The last part of this series (July 8, 2014) describes a second toolkit, released in June 2014, which focuses on antimicrobial stewardship.