Avoiding overuse of tests to prevent harm, eliminate waste, and reduce costs
The details behind proposed NPSG.16.01.01
After reading this article, you will be able to:
Define the rationale behind proposed NPSG.16.01.01
Identify appropriate tests, treatments, and procedures to assess
Understand how overuse of tests, procedures, and treatments affects patient safety
The Joint Commission recently proposed a new National Patient Safety Goal (NPSG) to take effect January 1, 2013, addressing overuse of treatments, tests, and procedures in order to reduce the risk of patient harm. The idea is that if evidence shows no benefit to an unnecessary test, treatment, or procedure, you are exposing a patient only to potential harm by performing it.
The proposed goal would require hospitals to implement a program to address the issue by selecting a test or treatment to focus on, evaluating and monitoring it, and implementing methods to decrease any overuse found along the way.
Hospitals may select a treatment, procedure, or test based on a risk assessment of their clinical services using evidence-based literature on the potential harm of a specific test to patients; or they may select a treatment, procedure, or test from a list in the proposed NPSG that is relevant to their services.
The list provided by The Joint Commission reflects growing attention to the safety and quality problems that unnecessary use of certain tests, treatments, or procedures can cause, and research has documented that overuse occurs with significant frequency in the United States. Should hospitals choose to select a test from the list provided by The Joint Commission, they will have to choose one of the following, relevant to the hospital's services:
- Early induction of labor in women at less than 39 weeks of gestation
- Insertion of tympanostomy tubes in children with otitis media and bilateral effusions of less than 60 days and without other symptoms
- Packed red blood cell transfusions in patients with hemoglobin of 12 grams or more
- Coronary stenting or balloon angioplasty for coronary stenosis of 40% or less
- CT scans for emergency department patients complaining of abdominal pain
The devil is in the details
In recent years The Joint Commission has moved to implementing NPSGs based on evidence-based research, and it's interesting to see that most of the procedures listed in the proposed NPSG are specific potential risks that have been of interest for quite some time and the topic of many recent studies.
For example, The Joint Commission released a Sentinel Event Alert in 2011 encouraging hospitals to decrease radiation exposure, so hospitals ought to be already looking at radiation exposure and decreasing unnecessary use of CT scans. In similar vein, the American College of Cardiology (ACC), the American Heart Association (AHA), and other organizations have released updated appropriate use criteria for coronary revascularization.
The fact that The Joint Commission is creating evidence-based NPSGs means that the case against them is harder to argue, but it also means that hospitals need to understand the rationale for such goals before implementing changes to procedures.
Dr. Manesh Patel, assistant professor of medicinein the Division of Cardiology at Duke University, and chair of the Appropriate Use Criteria committee for coronary revascularization for the ACC and the AHA, says that the criteria are not written for individual cases, but for patterns of care.
According to Patel, the data indicating that these procedures cause harm is actually not that easy to find. In fact, the Journal of the American Medical Association published a paper in July 2011 that looked at the cardiac catheterization and revascularization in the National Cardiovascular Data Registry and found that a majority of patients were getting appropriate revascularization procedures; only approximately 4% of cases involving stenting procedures were inappropriate.
However, Patel says this number could be misleading.
"As you might imagine, sometimes inappropriate procedures are performed on healthy patients, so if a procedure doesn't have the opportunity to notably make a patient better, then it is not clearly indicated," he says. "It doesn't always cause harm, it just may not be something that the patient has to undergo, which in turn may extend an unnecessary risk, potentially."
Reducing costs and waste
There is no doubt that this NPSG, should it become final, will reduce potential risks to patient safety, but it may also reduce waste and cost, says Patel, noting that there has been concern over waste for some time now.
According to Patel, a 2008 Medicare Patient Advisory Committee report announced that the healthcare industry spent $14.1 billion on medical imaging between 2006 and 2008, 35% of which was cardiovascular.
Patel says a significant portion of those healthcare costs were related to procedures.
"I'm not saying that all of that was waste, but anytime there's a large amount of money being spent on any one set of procedures, understanding whether they're appropriate or not is important, and that's why appropriate use criteria by the ACC are useful," he says.
But there is a snag.
Sue Dill Calloway, RN, MSN, JD, CPHRM, nurse attorney, president of Patient Safety and Health Care Consulting, and chief learning officer of the Emergency Medicine Patient Safety Foundation, says that many people resist change, whether it's good or bad, and in some cases, changing your practice could impact your pay.
"If you're a cardiologist and you're doing less PCI, less angioplasty, and you know you're currently part of the payment system for people who are not employees, which many cardiologists are not employees, the bottom line is that it could affect your pocketbook," she says.
However, Calloway warns that there are quite a few downfalls to overusing tests. She says that multiple adverse events have surfaced in recent years in relation to overuse of blood transfusions.
"It increases your length of stay, patients can go into renal failure, we saw increased morbidity and mortality, and we saw patients that went into pulmonary edema," she says.
Calloway adds that these guidelines can help prevent fraud and malpractice. "For example, you don't want to induce people for labor," she says. "There is nothing worse than doing an elective induction and ending up with a preterm baby. In fact, for most of us who are defense attorneys, it's pretty much considered to be malpractice."
The guidelines in the NPSG can also help hospitals with credentialing and privileging, Calloway notes.
"If you had a peer review issue with a cardiologist who you thought was ordering too many tests, this could help your case," she says.
Understanding the practice
Regardless of the research and studies that have been done, what will make all the difference is applying criteria and regulations, such as the Joint Commission standards and NPSGs, to medicine as a whole.
Patel says that in order for physicians to retain the viability of their profession and have what he terms "the privilege of self-regulation," there is a lot of pressure to evaluate how they practice. He says that organizations such as the ACC that actually have criteria should be commended. The healthcare community as a whole is striving to understand how physicians practice in order to move forward and progress.
"I think it's a great idea to say we want to reduce overuse; the question is always: How do you define it, how do you measure it, and how do you prevent it?" Patel says.
"So it's important that The Joint Commission thinks it's an important goal, but I think we're leading here in efforts to actually develop systems as a professional society to measure it, feed it back, and reduce it," he continues. "Hopefully we lead ourselves and self-regulate according to what the best practice is."
Chan P., Patel M., Klein L.W., et al. "Appropriateness of percutaneous coronary intervention." JAMA 2011; 306:53-61. Available at http://jama.ama-assn.org.