DVT project finds budget balance at the intersection of cost, quality

Two rather uncomplicated clinical practice changes could save one hospital system about $4 million over 1 year, proof that adopting a uniform best practice can improve the bottom line without sacrificing patient care.

The changes – switching from low-molecular-weight to unfractionated heparin and limiting postsurgical sequential compression devices to short-stay and outpatients only – consolidated practice and lowered expenses in eight hospitals in the Washington, D.C., area. If those same changes could be applied to larger systems, the associated health care savings could be enormous, according to Dr. John. R. Kirkpatrick, a former surgeon in the MedStar Health system and one of the forces behind the project.

Courtesy MedStar Health

"These savings were based on 120,000 surgeries in 1 year," he said in an interview. "There are 30 or 40 million surgeries done in the United States every year. So do the math – the savings could be almost $1 billion every year."

A report published in the April issue of the Journal of the American College of Surgeons describes the project’s genesis, implementation, and results (J. Am. Coll. Surg. 2013;216:800-13). The seed was planted in 2007, when Dr. Kirkpatrick stepped down from his post as the chair of surgery at MedStar Washington Hospital Center. He founded the Surgical Advisory Group, a company he described as a "surgical think tank" offering strategic planning aimed at increasing quality, operational efficiencies, and enhancing patient care.

Value, defined

The new team wanted to examine value in terms of health care – defining it as the intersection of quality and cost. They chose to investigate five perioperative variables: preoperative testing, prophylactic antibiotics, deep venous thrombophlebitis prophylaxis, operating room fluid resuscitation, and invasive monitoring in the OR. For each analysis, they would perform an extensive literature search to describe the currently accepted best clinical practice.

"The reason we chose DVT prophylaxis for the first case was that the data supporting the practices were so clear and compelling that they made our case," Dr. Kirkpatrick said. Studies clearly indicated that unfractionated heparin was just as effective as low-molecular-weight heparin, suitable for all but a select few patient types, and about 10 times cheaper. Low-molecular-weight heparin should be reserved for those cases and for patients who had experienced a DVT while on unfractionated heparin, the group advised.

Data also confirmed that sequential compression devices (SCDs) were most clinically and cost effective when used in the OR, at a price of about $22/stocking. Once the patient returned to the floor, however, the nursing time required to care for the device and patient noncompliance after discharge chipped away at the value without adding to quality. In-hospital daily cost could rise to about $150, and there was no way to even gauge the at-home cost, since many patients simply eventually abandoned the stockings.

Therefore, the group advised, SCDs should be employed only for outpatient or short-stay surgeries.

Assessing each hospital’s current practice was next. A survey sent to top hospital staffers and showed a wide variation in the use of both heparin and SCDs, Dr. Kirkpatrick said. "Four of the hospitals were already following the best practices," but the others were not.

It wasn’t immediately clear why four of the hospitals were almost exclusively using low-molecular-weight heparin and others, unfractionated heparin. Dr. Kirkpatrick said some use seemed related to institutional memory and whether the hospital served as a large teaching facility. Nevertheless, prophylaxis failure rates were similar (1%-1.8%) at all the facilities, confirming that both types of heparin effectively reduced DVT risk.

Stocking up on savings

While the average systemwide cost per dose was around $4, it varied widely depending on the type used: about $2.50 at the four centers using unfractionated heparin and $8.14 at those using low-molecular-weight heparin. The highest cost was $16.60 for low-molecular-weight heparin and the lowest, about $2, for unfractionated. Switching everyone to unfractionated heparin, except patients with failed prophylaxis or those special cases, was projected to save about $3 million/year.

The cost of SCDs was not as clear cut, since it included the difficult-to-measure "hidden costs" of extra nursing time to care for the stockings and loss of nursing time spent on other duties. But all of the facilities employed the devices in all surgical patients, regardless of the postoperative length of stay, at a materials cost of $22. Since 52% of the cases were outpatient or short-stay procedures, limiting the stockings to those patients alone was projected to save about $1 million each year.

The changes have been in place about 3-8 months now, depending on the facility, Dr. Kirkpatrick said. "The thing that changed immediately was the heparin usage. We saw immediately that we were going to get about $1.5 million in savings there. That put us almost to the halfway point of our projected $4 million. The compression devices will take a little longer to measure."

Getting the changes worked into the system wasn’t overly difficult, said Dr. Frederick Finelli, vice president of medical affairs at MedStar Montgomery Medical Center in Olney, Md.

"The physicians were mixed about how they felt about it," he said in an interview. "Some liked one heparin over another, for instance. We had to spend some time on getting a consensus, but we did work it through."

Implementing the medication change wasn’t hard either. The hospital system reorganized its computerized physician order entry system to offer unfractionated heparin as the default choice. "We made it easy to do the right thing and hard to do the wrong thing," Dr. Finelli said. "The algorithm for determining the right dosage is right on the order screen. The heparin is prioritized with unfractionated at the top of the list."

But a physician’s clinical judgment can still override the system, he added. "If you order the low-molecular-weight heparin, the instructions do come up saying that it’s recommended only for patients with cardiac surgery, trauma, or spinal cord injury. So you can still order it. If a physician understands what MedStar wants to do, but disagrees in a particular case, the low molecular weight is available. We think it’s a system that works."

Changes in the use of SCDs went into effect at the beginning of 2013, Dr. Finelli said. Physicians had to work to come to consensus on this point as well – and it was not as easily or thoroughly accomplished.

"There were some surgeons who really liked using them and not using an anticoagulant, so getting buy-in from them was not possible," said Dr. Finelli. This was especially true for those who dealt with cases in which bleeding would cause a great deal of harm, such as spine surgeries.

"These surgeons do continue to use the SCDs vs. heparin. So they do maintain control. We leave some leeway for it."

The next ‘best’ thing

The whole strategy gets a continual tune-up, he added. "We have an established committee of doctors, nurse practitioners, and information technology people who meet every 2 weeks to keep the process up to date."

In fact, flexibility is one of the best things about a value-based systems analysis, Dr. Kirkpatrick said. "We’re always looking for the new ‘best practice.’ What’s a best practice now could be obsolete in 2 years. We will keep updating what we do."

After just 8 months, some of that change may already be upon the program, Dr. Finelli said. In 2010 – 3 years after the Surgical Advisory Group began looking at the issue – low-molecular-weight heparin became available in a generic formula, narrowing the 10-fold cost differential.

"If the price drops low enough, we may want to switch that entire practice around. It’s much more attractive because it’s given once a day, there’s less nursing administration time, and greater patient satisfaction."

For now, though, it’s tough to ignore the total cost savings both practice changes will generate, said Dr. Kirkpatrick. "The reason it’s so significant is that those savings go right to the bottom line. A system like MedStar is very efficient, but the profit margins are still small – 1.5%-2%. There are not many $4 billion/year operations that can survive on a margin like that."

There’s always a cost – even to saving – and that, in the end, determines a project’s worth, said Dr. Stephen Evans, executive vice president of medical affairs and chief medical officer of MedStar Health.

"There are thresholds of cost usefulness. If you have a $40,000 savings, but it’s a laborious process to get there, that’s one thing. But a $4 million savings that’s relatively simple is obvious."

In this case, with the money going directly into the operational budget, the entire system benefits. "This is anew CAT scanner, or 10 new nurses. Part of the incentive for people to get costs under control is so they can look to reinvestment in the business. If everyone understands the goal of reinvestment, it’s a much greater incentive for everyone to participate."

Dr. Kirkpatrick is executive director of the Surgical Advisory Group. Dr. Evans and Dr. Finelli had no financial disclosures, other than their MedStar employment.

[email protected]

*Correction, 4/22/13: The photo caption in an earlier version of this story incorrectly identified Dr. Frederick Finelli. 

Two rather uncomplicated clinical practice changes could save one hospital system about $4 million over 1 year, proof that adopting a uniform best practice can improve the bottom line without sacrificing patient care.

The changes – switching from low-molecular-weight to unfractionated heparin and limiting postsurgical sequential compression devices to short-stay and outpatients only – consolidated practice and lowered expenses in eight hospitals in the Washington, D.C., area. If those same changes could be applied to larger systems, the associated health care savings could be enormous, according to Dr. John. R. Kirkpatrick, a former surgeon in the MedStar Health system and one of the forces behind the project.

Courtesy MedStar Health

"These savings were based on 120,000 surgeries in 1 year," he said in an interview. "There are 30 or 40 million surgeries done in the United States every year. So do the math – the savings could be almost $1 billion every year."

A report published in the April issue of the Journal of the American College of Surgeons describes the project’s genesis, implementation, and results (J. Am. Coll. Surg. 2013;216:800-13). The seed was planted in 2007, when Dr. Kirkpatrick stepped down from his post as the chair of surgery at MedStar Washington Hospital Center. He founded the Surgical Advisory Group, a company he described as a "surgical think tank" offering strategic planning aimed at increasing quality, operational efficiencies, and enhancing patient care.

Value, defined

The new team wanted to examine value in terms of health care – defining it as the intersection of quality and cost. They chose to investigate five perioperative variables: preoperative testing, prophylactic antibiotics, deep venous thrombophlebitis prophylaxis, operating room fluid resuscitation, and invasive monitoring in the OR. For each analysis, they would perform an extensive literature search to describe the currently accepted best clinical practice.

"The reason we chose DVT prophylaxis for the first case was that the data supporting the practices were so clear and compelling that they made our case," Dr. Kirkpatrick said. Studies clearly indicated that unfractionated heparin was just as effective as low-molecular-weight heparin, suitable for all but a select few patient types, and about 10 times cheaper. Low-molecular-weight heparin should be reserved for those cases and for patients who had experienced a DVT while on unfractionated heparin, the group advised.

Data also confirmed that sequential compression devices (SCDs) were most clinically and cost effective when used in the OR, at a price of about $22/stocking. Once the patient returned to the floor, however, the nursing time required to care for the device and patient noncompliance after discharge chipped away at the value without adding to quality. In-hospital daily cost could rise to about $150, and there was no way to even gauge the at-home cost, since many patients simply eventually abandoned the stockings.

Therefore, the group advised, SCDs should be employed only for outpatient or short-stay surgeries.

Assessing each hospital’s current practice was next. A survey sent to top hospital staffers and showed a wide variation in the use of both heparin and SCDs, Dr. Kirkpatrick said. "Four of the hospitals were already following the best practices," but the others were not.

It wasn’t immediately clear why four of the hospitals were almost exclusively using low-molecular-weight heparin and others, unfractionated heparin. Dr. Kirkpatrick said some use seemed related to institutional memory and whether the hospital served as a large teaching facility. Nevertheless, prophylaxis failure rates were similar (1%-1.8%) at all the facilities, confirming that both types of heparin effectively reduced DVT risk.

Stocking up on savings

While the average systemwide cost per dose was around $4, it varied widely depending on the type used: about $2.50 at the four centers using unfractionated heparin and $8.14 at those using low-molecular-weight heparin. The highest cost was $16.60 for low-molecular-weight heparin and the lowest, about $2, for unfractionated. Switching everyone to unfractionated heparin, except patients with failed prophylaxis or those special cases, was projected to save about $3 million/year.

The cost of SCDs was not as clear cut, since it included the difficult-to-measure "hidden costs" of extra nursing time to care for the stockings and loss of nursing time spent on other duties. But all of the facilities employed the devices in all surgical patients, regardless of the postoperative length of stay, at a materials cost of $22. Since 52% of the cases were outpatient or short-stay procedures, limiting the stockings to those patients alone was projected to save about $1 million each year.

The changes have been in place about 3-8 months now, depending on the facility, Dr. Kirkpatrick said. "The thing that changed immediately was the heparin usage. We saw immediately that we were going to get about $1.5 million in savings there. That put us almost to the halfway point of our projected $4 million. The compression devices will take a little longer to measure."

Getting the changes worked into the system wasn’t overly difficult, said Dr. Frederick Finelli, vice president of medical affairs at MedStar Montgomery Medical Center in Olney, Md.

"The physicians were mixed about how they felt about it," he said in an interview. "Some liked one heparin over another, for instance. We had to spend some time on getting a consensus, but we did work it through."

Implementing the medication change wasn’t hard either. The hospital system reorganized its computerized physician order entry system to offer unfractionated heparin as the default choice. "We made it easy to do the right thing and hard to do the wrong thing," Dr. Finelli said. "The algorithm for determining the right dosage is right on the order screen. The heparin is prioritized with unfractionated at the top of the list."

But a physician’s clinical judgment can still override the system, he added. "If you order the low-molecular-weight heparin, the instructions do come up saying that it’s recommended only for patients with cardiac surgery, trauma, or spinal cord injury. So you can still order it. If a physician understands what MedStar wants to do, but disagrees in a particular case, the low molecular weight is available. We think it’s a system that works."

Changes in the use of SCDs went into effect at the beginning of 2013, Dr. Finelli said. Physicians had to work to come to consensus on this point as well – and it was not as easily or thoroughly accomplished.

"There were some surgeons who really liked using them and not using an anticoagulant, so getting buy-in from them was not possible," said Dr. Finelli. This was especially true for those who dealt with cases in which bleeding would cause a great deal of harm, such as spine surgeries.

"These surgeons do continue to use the SCDs vs. heparin. So they do maintain control. We leave some leeway for it."

The next ‘best’ thing

The whole strategy gets a continual tune-up, he added. "We have an established committee of doctors, nurse practitioners, and information technology people who meet every 2 weeks to keep the process up to date."

In fact, flexibility is one of the best things about a value-based systems analysis, Dr. Kirkpatrick said. "We’re always looking for the new ‘best practice.’ What’s a best practice now could be obsolete in 2 years. We will keep updating what we do."

After just 8 months, some of that change may already be upon the program, Dr. Finelli said. In 2010 – 3 years after the Surgical Advisory Group began looking at the issue – low-molecular-weight heparin became available in a generic formula, narrowing the 10-fold cost differential.

"If the price drops low enough, we may want to switch that entire practice around. It’s much more attractive because it’s given once a day, there’s less nursing administration time, and greater patient satisfaction."

For now, though, it’s tough to ignore the total cost savings both practice changes will generate, said Dr. Kirkpatrick. "The reason it’s so significant is that those savings go right to the bottom line. A system like MedStar is very efficient, but the profit margins are still small – 1.5%-2%. There are not many $4 billion/year operations that can survive on a margin like that."

There’s always a cost – even to saving – and that, in the end, determines a project’s worth, said Dr. Stephen Evans, executive vice president of medical affairs and chief medical officer of MedStar Health.

"There are thresholds of cost usefulness. If you have a $40,000 savings, but it’s a laborious process to get there, that’s one thing. But a $4 million savings that’s relatively simple is obvious."

In this case, with the money going directly into the operational budget, the entire system benefits. "This is anew CAT scanner, or 10 new nurses. Part of the incentive for people to get costs under control is so they can look to reinvestment in the business. If everyone understands the goal of reinvestment, it’s a much greater incentive for everyone to participate."

Dr. Kirkpatrick is executive director of the Surgical Advisory Group. Dr. Evans and Dr. Finelli had no financial disclosures, other than their MedStar employment.

[email protected]

*Correction, 4/22/13: The photo caption in an earlier version of this story incorrectly identified Dr. Frederick Finelli. 

Two rather uncomplicated clinical practice changes could save one hospital system about $4 million over 1 year, proof that adopting a uniform best practice can improve the bottom line without sacrificing patient care.

The changes – switching from low-molecular-weight to unfractionated heparin and limiting postsurgical sequential compression devices to short-stay and outpatients only – consolidated practice and lowered expenses in eight hospitals in the Washington, D.C., area. If those same changes could be applied to larger systems, the associated health care savings could be enormous, according to Dr. John. R. Kirkpatrick, a former surgeon in the MedStar Health system and one of the forces behind the project.

Courtesy MedStar Health

"These savings were based on 120,000 surgeries in 1 year," he said in an interview. "There are 30 or 40 million surgeries done in the United States every year. So do the math – the savings could be almost $1 billion every year."

A report published in the April issue of the Journal of the American College of Surgeons describes the project’s genesis, implementation, and results (J. Am. Coll. Surg. 2013;216:800-13). The seed was planted in 2007, when Dr. Kirkpatrick stepped down from his post as the chair of surgery at MedStar Washington Hospital Center. He founded the Surgical Advisory Group, a company he described as a "surgical think tank" offering strategic planning aimed at increasing quality, operational efficiencies, and enhancing patient care.

Value, defined

The new team wanted to examine value in terms of health care – defining it as the intersection of quality and cost. They chose to investigate five perioperative variables: preoperative testing, prophylactic antibiotics, deep venous thrombophlebitis prophylaxis, operating room fluid resuscitation, and invasive monitoring in the OR. For each analysis, they would perform an extensive literature search to describe the currently accepted best clinical practice.

"The reason we chose DVT prophylaxis for the first case was that the data supporting the practices were so clear and compelling that they made our case," Dr. Kirkpatrick said. Studies clearly indicated that unfractionated heparin was just as effective as low-molecular-weight heparin, suitable for all but a select few patient types, and about 10 times cheaper. Low-molecular-weight heparin should be reserved for those cases and for patients who had experienced a DVT while on unfractionated heparin, the group advised.

Data also confirmed that sequential compression devices (SCDs) were most clinically and cost effective when used in the OR, at a price of about $22/stocking. Once the patient returned to the floor, however, the nursing time required to care for the device and patient noncompliance after discharge chipped away at the value without adding to quality. In-hospital daily cost could rise to about $150, and there was no way to even gauge the at-home cost, since many patients simply eventually abandoned the stockings.

Therefore, the group advised, SCDs should be employed only for outpatient or short-stay surgeries.

Assessing each hospital’s current practice was next. A survey sent to top hospital staffers and showed a wide variation in the use of both heparin and SCDs, Dr. Kirkpatrick said. "Four of the hospitals were already following the best practices," but the others were not.

It wasn’t immediately clear why four of the hospitals were almost exclusively using low-molecular-weight heparin and others, unfractionated heparin. Dr. Kirkpatrick said some use seemed related to institutional memory and whether the hospital served as a large teaching facility. Nevertheless, prophylaxis failure rates were similar (1%-1.8%) at all the facilities, confirming that both types of heparin effectively reduced DVT risk.

Stocking up on savings

While the average systemwide cost per dose was around $4, it varied widely depending on the type used: about $2.50 at the four centers using unfractionated heparin and $8.14 at those using low-molecular-weight heparin. The highest cost was $16.60 for low-molecular-weight heparin and the lowest, about $2, for unfractionated. Switching everyone to unfractionated heparin, except patients with failed prophylaxis or those special cases, was projected to save about $3 million/year.

The cost of SCDs was not as clear cut, since it included the difficult-to-measure "hidden costs" of extra nursing time to care for the stockings and loss of nursing time spent on other duties. But all of the facilities employed the devices in all surgical patients, regardless of the postoperative length of stay, at a materials cost of $22. Since 52% of the cases were outpatient or short-stay procedures, limiting the stockings to those patients alone was projected to save about $1 million each year.

The changes have been in place about 3-8 months now, depending on the facility, Dr. Kirkpatrick said. "The thing that changed immediately was the heparin usage. We saw immediately that we were going to get about $1.5 million in savings there. That put us almost to the halfway point of our projected $4 million. The compression devices will take a little longer to measure."

Getting the changes worked into the system wasn’t overly difficult, said Dr. Frederick Finelli, vice president of medical affairs at MedStar Montgomery Medical Center in Olney, Md.

"The physicians were mixed about how they felt about it," he said in an interview. "Some liked one heparin over another, for instance. We had to spend some time on getting a consensus, but we did work it through."

Implementing the medication change wasn’t hard either. The hospital system reorganized its computerized physician order entry system to offer unfractionated heparin as the default choice. "We made it easy to do the right thing and hard to do the wrong thing," Dr. Finelli said. "The algorithm for determining the right dosage is right on the order screen. The heparin is prioritized with unfractionated at the top of the list."

But a physician’s clinical judgment can still override the system, he added. "If you order the low-molecular-weight heparin, the instructions do come up saying that it’s recommended only for patients with cardiac surgery, trauma, or spinal cord injury. So you can still order it. If a physician understands what MedStar wants to do, but disagrees in a particular case, the low molecular weight is available. We think it’s a system that works."

Changes in the use of SCDs went into effect at the beginning of 2013, Dr. Finelli said. Physicians had to work to come to consensus on this point as well – and it was not as easily or thoroughly accomplished.

"There were some surgeons who really liked using them and not using an anticoagulant, so getting buy-in from them was not possible," said Dr. Finelli. This was especially true for those who dealt with cases in which bleeding would cause a great deal of harm, such as spine surgeries.

"These surgeons do continue to use the SCDs vs. heparin. So they do maintain control. We leave some leeway for it."

The next ‘best’ thing

The whole strategy gets a continual tune-up, he added. "We have an established committee of doctors, nurse practitioners, and information technology people who meet every 2 weeks to keep the process up to date."

In fact, flexibility is one of the best things about a value-based systems analysis, Dr. Kirkpatrick said. "We’re always looking for the new ‘best practice.’ What’s a best practice now could be obsolete in 2 years. We will keep updating what we do."

After just 8 months, some of that change may already be upon the program, Dr. Finelli said. In 2010 – 3 years after the Surgical Advisory Group began looking at the issue – low-molecular-weight heparin became available in a generic formula, narrowing the 10-fold cost differential.

"If the price drops low enough, we may want to switch that entire practice around. It’s much more attractive because it’s given once a day, there’s less nursing administration time, and greater patient satisfaction."

For now, though, it’s tough to ignore the total cost savings both practice changes will generate, said Dr. Kirkpatrick. "The reason it’s so significant is that those savings go right to the bottom line. A system like MedStar is very efficient, but the profit margins are still small – 1.5%-2%. There are not many $4 billion/year operations that can survive on a margin like that."

There’s always a cost – even to saving – and that, in the end, determines a project’s worth, said Dr. Stephen Evans, executive vice president of medical affairs and chief medical officer of MedStar Health.

"There are thresholds of cost usefulness. If you have a $40,000 savings, but it’s a laborious process to get there, that’s one thing. But a $4 million savings that’s relatively simple is obvious."

In this case, with the money going directly into the operational budget, the entire system benefits. "This is anew CAT scanner, or 10 new nurses. Part of the incentive for people to get costs under control is so they can look to reinvestment in the business. If everyone understands the goal of reinvestment, it’s a much greater incentive for everyone to participate."

Dr. Kirkpatrick is executive director of the Surgical Advisory Group. Dr. Evans and Dr. Finelli had no financial disclosures, other than their MedStar employment.

[email protected]

*Correction, 4/22/13: The photo caption in an earlier version of this story incorrectly identified Dr. Frederick Finelli.