Dare to differ: Team work, challenging vendors improves care, costs

ATLANTA—Improve quality, reduce cost. That’s often the goal, but less often the outcome. The leader of an integrated electrophysiology (EP) program shared a formula for achieving quality and savings June 13 at the Cardiovascular Service Line Symposium.

In 2010, Spectrum Health in Grand Rapids, Mich., purchased West Michigan Heart, a specialty practice group of about 30 cardiologists, to staff its Frederick Meijer Heart & Vascular Institute. Darryl Elmouchi, MD, formerly of West Michigan Heart and now the medical director of the Frederick Meijer Heart & Vascular Institute, became the point person for the emergency department for atrial fibrillation cases.

“A lot of things in medicine are born out of frustration,” he said. “We realized that how you treat atrial fibrillation in the acute setting is not standardized. There is poor literature on this. We decided to do something locally to make a difference.”

EP, general cardiology, internal medicine and emergency physicians collaborated to design an evidence-based protocol to safely treat patients and bypass admission by applying appropriate therapy expeditiously. They revised the approach after finding emergency room physicians sometimes still admitted patients if they felt follow-up was uncertain. The final result was the creation of an atrial fibrillation outpatient clinic in the EP suite.

The EP group runs the clinic and trained mid-level providers see the patients. If the patients have a referral, they are guaranteed to be seen in the clinic within 72 business hours. The physicians expanded the program to include patients seen by primary care physicians and the device clinic. The program emphasizes educating the patient and his or her family.

“The most important thing you can do is explain what atrial fibrillation is, what it means and what they will have to do in the future,” Elmouchi said. “Without that, people spin around in the system.”

Emergency room referrals to the clinic have grown from 34 patients in 2010 to 484 in 2012, and more than 1,000 patients have been triaged with the protocol. In a study of 100 consecutive patients, they found no negative outcomes, higher adherence to anticoagulation protocols and high patient satisfaction.

“This is something any integrated system can do when you have collaboration between multiple specialties and emergency departments to affect patient care,” he said.  

On the cost front, he offered a change they made in their device implantation procedures. Historically they kept patients overnight, although some were being coded as outpatients. They developed a protocol for same-day discharge for patients implanted with a pacemaker or defibrillator who met pre- and postprocedure criteria.

The catch was the need for a device check the next day, which would require patients to return to the facility. The physicians approached device vendors and said they wanted to be able to do same-day device monitoring. One vendor agreed to change its processes to accommodate them. Within about four or five months, other vendors "started remote monitoring in our site, whether as a pilot or as something they started doing nationwide,” he said.

In 2012, 65 percent of the newly implanted patients at the facility were coded as outpatients, and 80 percent met the criteria for a same-day procedure. More than 600 overnight stays were avoided, with no negative outcomes and high patient satisfaction.

“The bottom line is, it saved more than $1.3 million last year, solely by doing something that we thought would be better for patients,” Elmouchi said.