Fiscal Fitness Initiatives Generate Lasting Change

Several of Strong Memorial’s “rapid-cycle” quality improvement teams continue to do impressive work that simultaneously boosts care outcomes and the hospital’s bottom-line. In the first half of this year, the hospital has been able to shave $12 million in undue costs; by the end of December, URMC’s finance leaders anticipate that figure will climb to $21 million.

Two efforts in particular – the Department of Pharmacy’s work to safely rein in unnecessary drug expenditures, and the hospital’s goal to curb blood transfusions whenever possible – have not only met or outpaced their initial goals, but seem to have serious legs.

Cutting Pharmacy Expenses

Thanks to smart strategy, the Pharmacy’s rapid-cycle team – though initially charged with slicing $1 million off their annual drug spending – may actually save $1.3 million next year.

“We’ve been diligent about eliminating extra costs if they weren’t translating into better care quality,” said Pharmacy Director Curtis Haas, Pharm.D.

Three of the Pharmacy Department’s biggest successes to date include:

Scaling back use of high-cost drug therapies for the critically ill. Although these pricey medicines may offer a slight edge up for select ICU patients, using them across the board is unnecessary, Haas said, and markedly increases costs without necessarily offering extra benefit. To encourage physicians to employ alternative drugs when it makes good clinical sense, ICU clinical pharmacists have been working closely with critical care colleagues to make medicinal decisions on a case-by-case basis. This teamwork has ultimately helped trim the costs of therapy; for instance, use of an expensive medical sedative called dexmedetomidine has dropped more than 33 percent since last winter.

Using discretion when prescribing antibiotics. Libby Dodds-Ashley, Pharm. D., has taken on a massive educational challenge: urging residents and faculty to be more conservative in their choice to use antimicrobials (like piperacillin/tazobactam, also known as Zosyn). “Using these too liberally is poor stewardship,” Haas said. “Antibiotics are often unnecessary, and sometimes they can even impede a patient’s recovery. In the long term, using them generously also helps organisms develop resistance, ultimately rendering the medicines useless.”

Strong Memorial is making great strides; while the hospital used to spend $20 per-patient-per-day for antimicrobials, that number now hovers between $17 to $18 per-patient-per-day. “That’s the sort of figure you’d expect to see in a hospital where antibiotics are tightly controlled,” Haas said.

Making sure inhalers travel with patients. The Pharmacy has enjoyed some success in encouraging clinicians to prescribe appropriate – which in many cases, also happen to be more affordable – inhalers (abuterol inhalers, at about $14, cost six times less than Combivent versions). “We targeted a 40 percent decrease in Combivent inhalers, but achieved 70 percent,” Haas said.

But perhaps a bigger savings opportunity was ensuring that patients were not dispensed multiple inhalers (which can last two to four weeks each) during their short (on average 4- to 5-day) hospital stay. “We’ve started dispensing inhalers in bright, orange-labeled bags, so they’re not discarded or forgotten when a patient transfers from one part of the hospital to another,” Haas said. “We’ve also paid closer attention in the pharmacy system to identify duplicate inhaler requests. We’ve made sure that this issue is on everyone’s radar.”

Weighing When to Transfuse

Routine blood transfusions have come under scrutiny in recent years. No longer are these run-of-the mill hospital procedures considered benign; rather, they’ve been implicated for putting some patients at undue risk for infections.

URMC’s Director of Clinical Laboratories, Blood Bank, and Transfusion Medicine Neil Blumberg, M.D, is a nationally renowned expert on transfusion science. This September, he and colleague Richard Phipps, Ph.D., received a new $1.5 million, four-year grant from the National Heart Lung and Blood Institute to peel back the mystery of exactly how transfusions may trigger post-operative infections, and even blood clots.

“Neil and Richard’s research underscores just how dramatically our notion of ‘best practices’ are changing. The historical approach used to be fairly simple: If a hemoglobin level slipped below a given target, the patient would get blood,” said Paul Levy, Acting Chairman of the Department of Medicine. “But now, thanks to good science, we better appreciate the possible risks of this therapy. We’re more apt to cautiously observe the patient, restricting transfusions to only when safe and clinically necessary.”

Thanks to a rapid-cycle team that has zeroed in on cutting back routine blood product use – by revising the hospital’s transfusion guidelines, re-educating clinicians, and reconfiguring the electronic physician order entry system so that it now requires justification for requesting blood products – URMC staff are now more cautious about decisions to transfuse. Not only is this better medicine; this hard push has reduced blood product use by at least 20 percent in the past year – a savings at or in excess of $1 million.

This ideal – of becoming a more cost-conscious, methodical clinician who carefully weighs his or her options – is no flash-in-the-pan trend. In fact, it’s becoming a recurrent theme in modern medical education. William Novak, M.D., an assistant professor of Medicine at URMC, is even teaching new residents and mid-level providers to be savvy about when it makes good medical and fiscal sense to order tests, antibiotics, medicines, even blood products.

“We’re rapidly bringing the next generation of clinicians up to speed, teaching them how to make these decisions at the bedside,” Novak said. “In today’s economy, with so much pressure on health care systems to work efficiently, it’s absolutely critical that tomorrow’s physicians be taught to use resources wisely.”

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