Pneumonia is one of the highest volume DRGs in the country, so the ability to reduce clinical practice variation can have a significant impact on a provider’s quality of care and resource costs. We examined 183 cases from one hospital, and found several examples of wide variations in physician practice.
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Respiratory treatments. Several physicians wrote “open orders” for respiratory treatments, with patients receiving respiratory treatments every day until discharged. Other physicians adjusted orders to reduce or discontinue treatments during a patient stay. A protocol to establish clinical criteria to support medically necessary treatments was mutually agreed upon by the medical staff. The treatments for patients who did not meet the newly created clinical criteria were discontinued. The implementation of the protocol produced a 19% reduction in patients who initially received orders, and also generated significant labor savings in the respiratory therapy department.
Use of Medical Imaging. Variations in practice were noted in the utilization of chest x-rays, CT scans and inpatient MRIs. Many of the diagnostic images performed were not related to the patient’s primary diagnosis. The hospital implemented a physician “gatekeeper” to monitor compliance of pre-defined minimum criteria for all inpatient MRIs. Physician-directed implementation of best practices resulted in an overall reduction of inpatient MRIs by 22%.
Cardiac monitoring. Another outlying practice was the extent to which patients were put on cardiac monitors. Some physicians ordered cardiac monitors to a greater extent than others. This resulted in higher costs, and monitoring also resulted in longer lengths of stay. In fact, by the end of the stay, there were few treatments being performed, but the monitoring continued. Implementation of physician-directed best practices will reduce the use of telemonitoring to lower costs and length of stay, without impacting outcomes.
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