ATLANTA—A half billion here, almost another billion more there. Cardiologists can contribute to cost savings and revenues, but it may take compelling data and frequent reminders, judging by the example of Providence Spokane Heart Institute in Washington.
“Where there is variation, there generally is opportunity,” Braden W. Batkoff, MD, president and medical director of the heart institute, said June 11 at the MedAxiom Cardiovascular Service Line Symposium in Atlanta. He detailed four cost-saving initiatives that in total saved $535,000 and created a potential $994,000 by freeing up hospital beds.
In 2014, the institute took a multipronged approach to cost savings, looking at opportunities as varied as the supply chain to same-day discharge for PCIs. The efforts began with a review of the evidence. For instance, after finding little clinical difference among available stents, they established a two-vendor deal for stents and a three-vendor deal for electrophysiology items to lower costs.
“In my view, this is service line 101,” Batkoff said. “It is the low-hanging fruit.”
Changes in patient care are more complex and potentially disruptive, he noted. A systemwide analysis of anticoagulation after PCI showed wide variation in the use of bivalirudin (Angiomax, The Medicines Company). That variation combined with recent data on less expensive unfractionated heparin prompted them to update recommendations for cardiologists.
The use of bivalirudin at their hospital decreased from 70 percent in January 2014 to 16 percent by the end of the year, for a cost savings of $200,000. They found no changes in outcomes.
Yet another project targeted the use of the Coronary Care Unit (CCU) for STEMI cases, which was also variable across the hospital system. Based on guideline recommendations, they changed the criteria for admission.
Over the year, they reduced their CCU use by about 25 percentage points, or 65 patients, for a cost savings of $143,000. “More importantly for us is we now created capacity for 65 CCU beds for other patients to now be admitted to our institution,” Batkoff said. They estimated the potential increased revenue from freeing up beds at $455,000.
The heart institute’s fourth program was inspired by the clinical success of same-day discharge for elective PCI procedures they found in the literature. Interventional cardiologists developed patient inclusion criteria for the program, and they began tracking use of same-day PCI discharges down to the physician level. That data as well as safety results are shared at monthly meetings.
The use of same-day discharges for elective PCIs reached 25 percent by the end of the year and by April 2015 hit 37.5 percent. They calculated the program has saved $192,000 in costs with potential bed capacity savings of $539,000.
“I feel we are making great progress and our physicians and staff have rallied around this initiative,’ he said. The electrophysiology group is now looking at starting a same-day discharge program for some patients who receive pacemakers and implantable cardioverter-defibrillators.
These initiatives require physician leadership, measuring, documentation and constant communication to be successful, he said. “You need regular feedback. You need to keep it in front of the physicians,” he said. “In terms of value, as physicians we need to measure what we do, we need to document what we do and we need to communicate the results."