Framing the issue:

  • Bending the health care cost curve has become something of a mantra given the nation's fiscal realities.
  • The appropriate use of medical resources is based on evidence that particular tests and treatments do not put patients in harm's way and do deliver the best outcomes.
  • Evidence-based decisions eliminate unnecessary tests and treatments and, thus, save money.
  • Both physicians and consumers must be taught that more care is not the same as better care.
  • As part of a new initiative, the AHA recommends five types of clinical care that providers and practitioners should consider more carefully.

Another day for a heart surgeon, another coronary artery bypass graft. Can't forget to order the usual two pints of blood. But hold on a minute. Has anyone pointed out the recent evidence that shows one pint is usually enough? That overusing transfused blood can increase infection risk, reduce immune response, extend a hospital stay? Time to rethink, maybe change, the policy on blood usage.

In the emergency department, a Medicare patient complains to the doctor about his lower-back pain of the last few weeks. This man needs a CT scan, the physician immediately concludes. That would pick up a bulging disk, which surgery could correct. But hold on a minute. Studies have shown that if all people his age had a CT scan, half would show a bulging disc, often not tied to any symptoms. The finding by itself is insufficient reason for a hospital stay, much less back surgery. The upshot: There's little call for the scan here.

Similar unnecessary use of resources, against evidence, can result from hospitalizing for simple pneumonia, doing a brain scan for chronic isolated headache and performing elective cardiac catheterization instead of trying drugs first. These frequently employed treatments and diagnostics add risk to patients, as well as expense. If health care is to survive the transition to value-based, fixed payment, the proliferation of costly care with questionable quality can't go on much longer.

"I think everyone sees the writing on the wall. No matter what the model for the future holds exactly, it's clear that the cost curve cannot continue the way it is," says Ken Sands, M.D., senior vice president for health care quality at Boston's Beth Israel Deaconess Medical Center. "I think everyone acknowledges that, and the health of the nation requires we get health care spending under control so that those resources can be used in other ways."

Scrutiny is here

Sands is chair of the American Hospital Association's Committee on Clinical Leadership, which provided guidance for a report on stewardship of the limited and decreasing resources available for patient care. The 20-page summation of this initiative, "Appropriate Use of Medical Resources," makes the case for why some inpatient-oriented tests and procedures should be given a hard look, the reasons that physicians have come to overuse certain tools and treatments, and five types of clinical care that the AHA is committing to curtailing in the next few years.

Facing this era of constrained resources and rising costs, "it's really incumbent upon us to use those limited resources much more wisely than we were doing in the past," says John Combes, M.D., AHA senior vice president and chief operating officer of the AHA's Center for Healthcare Governance. "The message is, for both patients and practitioners, to consider before doing something: Is the benefit worth the risk, and is this effective and efficient in terms of cost to the overall health care system?"

With the shift to demonstrating value, the pressure on pricing and a gradual increase in managing medical risk with finite contract income, "we're suddenly looking at things that we were dancing over, we were reluctant to touch, we didn't understand," says Lee Sacks, M.D., a member of the AHA's leadership committee and executive vice president and chief medical officer of Advocate Health Care, Downers Grove, Ill.

The starter set of scrutinized services being put forward by the AHA consists of blood management, antibiotic stewardship, appropriate ICU use for the terminally ill, reduction of inpatient admissions for conditions that shouldn't be treated in that setting, and reduction of elective heart catheterizations. But in due time, "we're going to see this kind of scrutiny in virtually everything," Sacks says.

The utilization-review slide

Up until about the mid-1990s, an ingrained resource evaluation process known as utilization review and management was a high priority, says Combes. "Utilization review held sway as the way to control quality, to guarantee that there wasn't overusage and also to look at making sure that people got what they needed."

In 1999, that priority began to be nudged lower by a shift to patient safety, he says, a focus triggered by the Institute of Medicine clarion call, "To Err is Human: Building a Safer Health System." Because of resources diverted to safety — and a growing backlash against utilization-review tactics associated with managed care organizations at that time — utilization management "sort of disappeared for a while," he says. That created a climate for making decisions about safety "which some clinicians thought required more intervention without really considering if this placed the patient more at risk."

The emphasis during the past decade on patient safety and preventing harm did foster an understanding that all health care procedures and interventions come with some risk. Part of the new push for resource stewardship is to make sure that medical tests and procedures are used judiciously to minimize risk and maximize benefit, Combes explains.

In the 1990s, managing care began to be equated with managing cost, says Mark Adams, M.D., chief medical officer of Franciscan Health System in Tacoma, Wash. "It made us feel as though we were withholding treatment because of money," he says. What the health care field needed was a new approach that puts quality up front, delivering care such that it has the extra effect of saving money, but that's not the main intent, says Adams, a member of the AHA's leadership committee.

'Enamored with technology'

Technology has improved the odds for clinicians' fighting serious disease, but dependence on diagnostic testing and consequent inpatient care for procedures can increase the cost when alternative approaches would provide the same benefit for patients at less expense and risk, Combes says.

Over the years, many interventions have become "a lot more technically feasible and easy to do, and both the profession and patients have become enamored with the technology," with its prospects of "quick fixes" for a problem, he says. One example: performing invasive cardiac procedures for a not-yet-critical narrowing of a coronary artery when a drug could provide the same outcome but over a longer time period. "People will tend to go for the easier intervention, but the problem is that it introduces more risk than taking the drug therapy, and it is much more expensive," Combes says.

"Consumers have a big role in this, too," Adams adds. Patients want the latest test, the latest antibiotic. "Consumers were willing participants" in the decision-making, and there have been few brakes on that demand.

"Under the traditional fee-for-service model, physicians had free rein to order tests, to perform procedures, and there was an incentive to do so in [financial] terms, but also in terms of patients' perceiving that as good care," Sands says. "All the incentive was in the direction of doing more. And acknowledging that there can be a gray area in terms of when the test is needed or not, it was very easy to go in the direction of overuse."

Improved diagnostic tests pick up issues that are incidental to a patient's condition, leading to more tests and invasive procedures for an anomaly that either wouldn't have amounted to anything or would not have contributed useful information. There's even an ironic term for that, incidentaloma, characterized by overaggressive clinical reaction to chance detection of a suspicious something on a scan.

Further pulling physicians in the direction of overuse is the maxim "traditionally taught either directly or subtly, that a good clinician is a thorough clinician who does all potentially useful tests," Sands adds. "The 'no stone unturned' was where a lot of the value and admiration came from when you were a physician in training."

The result of all these forces is that "every clinician lives in fear of missing a diagnosis, not just for liability reasons but because that's how they define themselves as being good clinicians," he says. "And they traditionally have lived in considerably less fear of overutilization. It wasn't something that directly affected them."

Fewer resources, more concern

Those days may be coming to an end. For medical groups and health systems, payer reactions to rising costs — along with the rising prices of medical supplies — have ushered in an era in which "the resources available are significantly less now," says William Pinsky, M.D., executive vice president and chief academic officer of
Ochsner Health System, New Orleans, and another AHA leadership committee member.

Appropriate use of medical resources is a natural outgrowth of such concern. Both hospital administrators and physician leaders "basically see this as something important to the viability of their practice setting or wherever they deliver care," says Pinsky, adding, "I frankly think it's always been a responsibility, and we have always talked about it, but we haven't had a systematic way of making this a part of what we do."

The American Board of Internal Medicine took on that systemization, challenging each specialty's medical society to identify five things physicians and patients should question and discuss. The program arising from Choosing Wisely, the ABIM Foundation initiative, aims to reduce frequently ordered tests and procedures, often in favor of alternatives with more evidence of better value and lower risk.

Overwhelming response from the physician community, whose contributions to the list exceed 250 items and continue to grow, "acknowledges that health care has transitioned from fee-for-volume to fee-for-value, that the transition is occurring today and that the trend will continue," says Scott Weingarten, M.D., senior vice president and chief clinical transformation officer at Cedars-Sinai Medical Center, Los Angeles. The guidance of the ABIM signals willingness to go along with that transition and is in part meant to help physicians succeed in this new world of health care, says Weingarten, who has helped to embed clinical decision support at Cedars-Sinai to target more than 100 of the tests and procedures on the scrutiny list.

The AHA campaign kicks off with the same group-of-five approach, with a wrinkle: It emphasizes decisions about what to do and not do in the hospital setting, whereas medical societies have focused largely on the intricacies of evidence for or against clinical practices. The Committee on Clinical Leadership "wanted to make sure we were not preaching to others," Combes says. "We're the American Hospital Association and we were making recommendations back to our own field about this."

The chosen situations "were most strongly affected by the system in which they were delivered," says Elisa Arespacochaga, director of the AHA's Physician Leadership Forum, which includes the leadership committee. "So the hospital has a strong control over these specific five, and could put systems in place to help people understand that they need to consider the options and have a conversation."

Guiding resource choices

Unlearning the "no stone unturned" approach will be difficult for doctors, but"if you can get a small minority of the clinical leaders whom others look up to as highly skilled, highly knowledgeable clinicians, and get them to voice the change, then others will follow," Sands says.

Well-informed clinicians have the task of explaining the choices to patients. A key piece of the AHA initiative is to create toolkits with materials to have in hand for the conversation. Each kit will have discussion guides for physicians, information packets for patients and implementation guides for institutions.

The first toolkit, released in April, takes on appropriate blood management in inpatient services and was developed in conjunction with AABB, the professional society for transfusional medicine. Successive toolkits will be issued approximately each quarter.

Combes stresses that the goal is "to engage the patient early in the discussion about treatment options and the pluses and minuses of each option. The data suggest that the more the patient is engaged in care decision-making, the more conservative that patient will be in choosing treatment options."

John Morrissey is a freelance writer in Mount Prospect, Ill.