Measuring Hospital-Acquired Complications Associated With Low-Value Care

Does my patient really need this at admission? Seven opportunities for improving value in patient care during their hospitalization

INTRODUCTION

Besides the main treatment for their disease, hospital patients receive multiple care measures which include venous lines (VL), urinary catheters (UC), dietary restrictions (DR), mandatory bed rest (BR), deep venous thrombosis prophylaxis (VTP), stress ulcer prophylaxis (SUP) and anticoagulation bridge therapy for atrial fibrillation (BAF). In many cases these practices are of low value.

METHODS

We analysed patients admitted to Internal Medicine wards throughout 2018 (2714 inpatients). We used different methodologies to identify low-value clinical practices.

RESULTS

BR or DR at admission were recommended in 37% (32-44) and 24% (19-30) of the patients respectively. In 81% (71-87) and 33% (21-45) of the cases this restriction was deemed unnecessary. Ninety-six percent (92-98) had VL and 25% (19-32) UC. VL were not used in 10% (6-12), UC had no indications for insertion in 21% (11-35) and for maintenance in 31% (12-46) patients. Fifty-seven percent (49-64) of the patients were administered VTP and 69% (62-76) were prescribed SUP. Twenty-two percent (15-31) of patients with VTP and 52% (43-60) with SUP had no indication. Chronic anticoagulation for AF was interrupted in 65% (53-75) with BAF was prescribed in 38% (25-52) of them. An intervention to reduce low-value care supporting clinical practices addressed only to the Internal Medicine Wards showed very poor results.

CONCLUSION

These results demonstrate that there is ample room for reduction of low-value care. Interventions to implement clinical guidelines at admissions should be addressed to cover the entire admission process, from the emergency room to the ward. Partial approaches are discouraged.

Infusing High Value Care Education Directly into Patient Care on the Medicine Wards

This article was migrated. The article was marked as recommended. Background: Multiple national initiatives have been implemented to promote cost-conscious care. Yet, there remains a deficiency of formal high value care (HVC) curricula among internal medicine residency programs.We aimedto develop a curriculum that teaches HVC material that can be utilized at the point of care and to assess the curriculum's impact on the participants' attitudes, knowledge, and practice patterns pertaining to HVC. Methods: We conducted our study on the inpatient internal medicine service over two-week rotations at Johns Hopkins Bayview Medical Center. Internal medicine residentsparticipated in two collaborative educational sessions that incorporated an introduction of important concepts in HVC, Bayesian thinking, clinical cases, and a review of a hospital bill of one of the patients under the team's care. Participants were also encouraged to reflect on their practice patterns and incorporate the HVC principles taught into their daily clinical work. We administered pre- and post-curriculum surveys to assess change in reported HVC-related practice behaviors, knowledge, and attitudes. Results: Forty-seven residents participated in the study. We included the twenty participants who completed both a pre- and post-curriculum survey in the data analysis. After participation in the curriculum, there was a significant increase in the use of pre-test probabilities in clinical decision making ( p=0.005). There was also a trend toward improvement in HVC knowledge and practice patterns after the rotation. Conclusion: We implemented a curriculum that may have improved high-value practice patterns through point-of-care education on the inpatient medicine wards.