Amid a challenging reimbursement scenario, Providence Spokane Heart Institute in Spokane, Wash., managed to trim more than $500,000 in costs in 2014 without compromising care in its PCI programs. The targets? Anticoagulation options, intensive care utilization and same-day discharges. Braden W. Batkoff, MD, executive medical director, discussed the projects with Cardiovascular Business.
How did you choose these initiatives? Did you have a process?
We sat down as a cardiology group within our heart institute and came up with some recommendations. We brainstormed and these rose to the top in terms of feasibility and opportunities for savings. We looked at our baseline state and processes and realized there were opportunities and combined that with literature reviews and searches to find innovative programs elsewhere that had initiated similar programs.
Did you roll these projects out simultaneously?
We started in late 2013 and had work going in parallel. It was a lot of work but we put the groundwork in ahead of time. We had a good team around us and a lot of support staff who allowed that to happen. We worked with our administrative team, our nursing team and the rest of the clinical team to look at the pathways, address potential barriers and then talk about an implementation strategy.
What kind of responses did you get from the cardiologists at the beginning?
It varied. We had a spectrum, as you would expect. Some immediately embraced it and some were more hesitant. As we began to build trust with our colleagues and worked toward demonstrating the results, we got more and more buy-in.
We had open discussions about the current state, looked at other practices and tried to move forward in a unified fashion. We had regular phone conversations and meetings to disseminate the findings and results; that was key to getting participation and buy-in.
Several of these initiatives we started at our facility but they were carried out on a systemwide basis as well. It was always helpful to draw upon the experience of our colleagues who were potentially farther along on the spectrum of the initiatives and learn from their experiences.
How did you maintain your gains?
At all of our cath lab and patient care meetings, we reviewed our data on participation and utilization. We continued to put that data in front of cardiologists on a monthly basis. It was a strategy we used in the past and it clearly was helpful with these projects as well.
We continue to track both our clinical and our participation/utilization data. What we have seen to date is consistent clinical quality and no change in outcomes and continued participation, which continues to increase.
What did the cost savings allow you to do?
In our healthcare environment, we are constantly being asked to do more with less resources. As a service line, we were able to divert some of those funds to other activities that needed additional resources.
It seemed like the same-day PCI program just started to get momentum in 2014. Where is it now?
To date we are up about 50 percent from our levels at the end of 2014. We continue to show progress in participation in same-day discharge. As our physicians and patients become more comfortable with that concept, we expect to see that to continue to grow.
Is there a lesson that stands out with the same-day PCI program?
The key was really in the process. We started with our physician group getting together and reviewing the data and the guidelines. We also looked at some programs that published early data suggesting equivalent outcomes with same-day discharge compared with overnight hospital stays.
For that project we assembled a multidisciplinary team with our nurses, our administrative team and our pharmacists. We had to redesign our workflow and care pathways. The key there was involving the appropriate individuals at the onset. We really worked as a team to see that program through implementation.
Is there one particular project you are proud of?
I am particularly proud of our same-day PCI discharge because we took that from concept to implementation in a 90-day period with the help of our team and showed continued progress over the course of last year and into this year.
Do you have other projects you initiated in 2015?
In 2015 we sat down with our EP [electrophysiology] colleagues and they are in the process of initiating a same-day discharge program for pacemakers and ICD [implantable cardioverter-defibrillator] implantation for low-risk patients. We are looking in more detail in terms of our cost-per-case analysis for both PCI and our EP procedures and want to tackle on a broad basis our total cost of care by DRG [diagnosis related group].
Three Ways to Save Money
Heparin vs. Bivalirudin
Opportunity—Bivalirudin, the standard of care for anticoagulating PCI patients, costs more than unfractionated heparin. Based on recent evidence that showed equivalent outcomes, the cardiology team recommended heparin as an alternative.
Results—Bivalirudin use dropped from 79 percent in January to 16 percent in December with no change in outcomes. The institute saved its hospital, Sacred Heart Medical Center, $200,000 that year.
Cardiac Intensive Care
Opportunity—Rather than admitting all STEMI patients to intensive care after a procedure, interventional cardiologists sent only those who met defined criteria to intensive care and assigned the others to the telemetry floor.
Results—The usage rate for cardiac intensive care decreased from 61 percent in January to 35 percent in December for a direct cost savings of $143,000.
Same-day PCI Discharge
Opportunity—Low-risk PCI cases successfully had been discharged without an overnight stay at other centers. A multidisciplinary team at the institute developed a process for identifying elective PCI candidates and changed the care pathway to allow for same-day discharge PCI.
Results—A total of 77 patients were discharged on the same day as their procedures for direct cost savings of $192,000.