Objective: Low quality and unwarranted clinical variation harm patients and increase unnecessary costs. Effective approaches to improve clinical and economic value have been difficult. The Ochsner Health System looked to improve clinical care quality and reduce unnecessary costs in cardiology using active measurement and customised feedback.
Methods: We serially measured care decisions using online, simulated cases to capture clinical details of cardiology practice and provide individual feedback. Fifty cardiologists cared for two simulated patients in each of six assessment rounds occurring 4 months apart. Simulated patients presented with heart failure (HF), coronary artery disease (CAD), supraventricular tachyarrhythmia (SVT) or valvular heart disease. Using Ochsner's patient-level data, we performed real-world pre-post analyses of physician practice changes, patient outcomes and costs.
Results: Between baseline and final rounds, overall simulated quality-of-care scores improved 14.1% (p<0.001). In the same period, we found cost-of-care variation decreased in patient-level data, with larger decreases for more severely ill patients. The total per-patient direct costs decreased $493 in SVT, $305 in HF and $55 in CAD (p<0.05 for SVT and HF). Readmission rates fell significantly for HF (from 20.0% to 11.9%) and SVT (from 14.5% to 7.8%) (both p<0.001) and non-significantly for CAD (from 13.7% to 11.3%, p=0.112). The cost avoidance/revenue generation opportunity from reduced readmissions and direct costs amounted to annual savings of $4.34 million, with no significant changes to in-hospital mortality rates (p>0.05).
Conclusions: Using simulated patients to serially measure and provide individual feedback on clinical practice significantly raises quality and reduces practice variation and costs without negatively impacting outcomes.
Keywords: arrhythmia; clinical variation; coronary artery disease; evidence-based medicine; heart failure; patient outcomes; quality improvement.