Myeloid growth factor utilization in a commercial and Medicare population: Phase 1 of a quality improvement initiative.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 242-242
Author(s):  
Edward C. Li ◽  
Barry A. Peterson ◽  
Cecilia Tran ◽  
Michael Sturgill ◽  
Dudley Gill ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Phase 1 ◽  
Cost Savings ◽  
Cost Effective ◽  
Secondary Prophylaxis ◽  
Quality Improvement Initiative ◽  
Curative Intent ◽  
Medicare Population ◽  
Concurrent Use ◽  
Chemotherapy Dose

242 Background: Some clinical practice guidelines encourage the judicial use of myeloid growth factors (MGFs) in the prevention of chemotherapy-induced febrile neutropenia (FN) because of efficacy and safety concerns. For example, the ASCO guidelines state that a dose reduction of myelosuppressive chemotherapy in patients with incurable disease rather than prescribing a MGF for secondary prophylaxis is a reasonable alternative. Because there is wide variation in MGF prescribing, New Century Health (NCH) conducted a quality improvement analysis of MGF requests in a commercial and Medicare population. The objectives are to: (1) describe the cohort demographics, (2) identify areas of improvement to promote cost-effective use, and (3) measure the economic impact from interventions. Methods: MGF authorization requests for oncology indications to NCH in 2013 were analyzed for cohort demographics: age, weight, tumor diagnosis, and treatment intention (e.g., metastatic/palliative, curative, etc.). Requests were analyzed for concurrent use with chemotherapy, approval status of the request (including reason for withdrawal), and cost saving associated with interventions. Results: There were 7,958 requests for a MGF; 81% were for pegfilgrastim and 19% for filgrastim. Average age of the cohort was 66 years, weight-based dosing (>70 kg) was appropriate in 43% of patients receiving 300 mcg and 72% of patients receiving 480 mcg. MGFs were most commonly requested in: breast (18%), lung (17%), lymphoma (14%), and gynecologic (8%) tumors. 40% of requests were for metastatic/recurrent disease and 38% for curative intent. 6,724 (84%) of requests were authorized based on established-use criteria. The main reason for not authorizing was lack of compendia support for both primary and secondary prophylaxis; this resulted in approximately $3.5 million in cost savings. Conclusions: There is opportunity to improve efficiency of MGFs use in this population through a dose rounding protocol and by promoting chemotherapy dose reductions, as advocated by the ASCO guidelines. Further analysis will assess the concordance of MGF use with guidelines, specifically in regard to chemotherapy regimens and their risk of FN.

Assessment of Cost-Effective Antibiotic Therapy in the Management of Infections in Cancer Patients

1994 ◽  
Vol 28 (1) ◽  
pp. 105-111 ◽  
Author(s):  
Michael A. Cimino ◽  
Coleman M. Rotstein ◽  
Jason E. Moser
Keyword(s):  
Quality Improvement ◽  
Antibiotic Therapy ◽  
Clinical Pharmacist ◽  
Hospital Setting ◽  
Cost Savings ◽  
Cost Effective ◽  
Baseline Period ◽  
Economic Benefits ◽  
Consensus Approach ◽  
Quality Improvement Effort

OBJECTIVE: To describe the economic benefits of a quality improvement effort directed at optimizing clinical outcome. DESIGN: A before—after observational design was used to evaluate the cost-effectiveness of a consensus approach to antimicrobial therapy. SETTING: The evaluation was conducted at a cancer research hospital. PATIENTS: Oncology patients requiring parenteral antibiotic therapy were consecutively observed. MAIN OUTCOME MEASURES: Outcome (clinical and microbiologic response), safety, and cost of therapy were assessed during a baseline period and compared to a period during which the consensus approach was used. INTERVENTIONS: The influence of a designated individual, in this case a clinical pharmacist, responsible for promotion of the consensus approach was explored. RESULTS: The consensus approach in combination with the promotional efforts of the clinical pharmacist was associated with a 13 percent increase in overall clinical response and a reduction of pathogen persistence from 22 to 11 percent. No difference in the average number of adverse effects per patient was observed over the two observation periods. These findings were associated with an estimated $22000/month cost savings. The consensus approach alone, without benefit of the clinical pharmacist, was not associated with improved therapeutic outcome or cost savings over the same observation periods. CONCLUSIONS: These data suggest that a consensus approach to antibiotic therapy can be cost-effective. An individual, such as a clinical pharmacist, may add significantly to quality improvement and cost-effective efforts in a hospital setting.

Impact of an Interprofessional Collaborative Quality Improvement Initiative to Decrease Inappropriate Thyroid Function Testing

2020 ◽  
pp. 001857872092079
Author(s):  
Alyssa B. Bradshaw ◽  
Alex K. Bonnecaze ◽  
Cynthia A. Burns ◽  
James R. Beardsley
Keyword(s):  
Quality Improvement ◽  
Thyroid Function ◽  
Medical Center ◽  
Cost Savings ◽  
Thyroid Stimulating Hormone ◽  
Quality Improvement Initiative ◽  
Published Data ◽  
Free T4 ◽  
Potential Cost ◽  
Before And After

Background: Published data show that thyroid function laboratory tests are often ordered inappropriately in the acute care setting, which leads to unnecessary costs and inappropriate therapy decisions. Pilot data at our institution indicated that approximately two-thirds of the thyroid-stimulating hormone (TSH) laboratories were unnecessary, correlating to a potential cost avoidance of more than $20,000 annually. The purpose of this study was to improve the appropriateness of thyroid function test ordering with a multipronged initiative. Methodology: This controlled, single-center, before and after study included inpatients or emergency department (ED) patients at Wake Forest Baptist Medical Center who were at least 18 years of age and had a TSH level ordered during the study period. Patients with a history of thyroid cancer were excluded. The initiative included an electronic ordering intervention, direct education of providers (medical residents, attendings, and clinical pharmacists), and distribution of pocket information cards with appropriate ordering criteria. The primary outcome was the number and percentage of inappropriate TSH tests ordered before and after implementing the 3 interventions. Secondary outcomes included cost savings, inappropriate changes in thyroid therapy based on improperly ordered tests, and the number of free T4 lab tests ordered on patients with a TSH within the therapeutic range. Results: All 3 interventions were implemented, except for education of ED residents and faculty, who chose to forgo the direct education component. Inappropriate ordering of TSH levels decreased from 63 to 50 (13% reduction, P = .062) after implementation. Inappropriate TSH ordering decreased across all services, except in the ED. Inappropriate Free T4 orders decreased from 191 to 133 (30% reduction, P = .01). There were no therapy changes based on inappropriate TSH orders. Extrapolated annual cost savings were approximately $6,000. Conclusion: This multipronged interprofessional collaborative quality improvement initiative was associated with a nonstatistically significant reduction in inappropriate TSH orders, statistically significant reduction in inappropriate free T4 orders, and cost savings. There was a reduction in inappropriate ordering across all services except the ED, which may have been due the ED not participating in the direct education component of the initiative.

scholarly journals Learning from a clinical microsystems quality improvement initiative to promote integrated care across a falls care pathway

2018 ◽  
Vol 20 ◽  
Author(s):  
Kate Gerrish ◽  
Carol Keen ◽  
Judith Palfreyman
Keyword(s):  
Quality Improvement ◽  
Care Pathway ◽  
Phase 1 ◽  
Healthcare Providers ◽  
Decision Makers ◽  
Complex Nature ◽  
Quality Improvement Initiative ◽  
Care Providers ◽  
Integration Of Care ◽  
Clinical Microsystems

Abstract Aim To identify learning from a clinical microsystems (CMS) quality improvement initiative to develop a more integrated service across a falls care pathway spanning community and hospital services. Background Falls present a major challenge to healthcare providers internationally as populations age. A review of the falls care pathway in Sheffield, United Kingdom, identified that pathway implementation was constrained by inconsistent co-ordination and integration at the hospital–community interface. Approach The initiative utilised the CMS quality improvement approach and comprised three phases. Phase 1 focussed on developing a climate for change through engaging stakeholders across the existing pathway and coaching frontline teams operating as microsystems in quality improvement. Phase 2 involved initiating change by working at the mesosystem level to identify priorities for improvement and undertake tests of change. Phase 3 engaged decision makers at the macrosystem level from across the wider pathway in achieving change identified in earlier phases of the initiative. Findings The initiative was successful in delivering change in relation to key aspects of the pathway, engaging frontline staff and decision makers from different services within the pathway, and in building quality improvement capability within the workforce. Viewing the pathway as a series of interrelated CMS enabled stakeholders to understand the complex nature of the pathway and to target key areas for change. Particular challenges encountered arose from organisational reconfiguration and cross-boundary working. Conclusion CMS quality improvement methodology may be a useful approach to promoting integration across a care pathway. Using a CMS approach contributed towards clinical and professional integration of some aspects of the service. Recognition of the pathway operating at meso- and macrosystem levels fostered wider stakeholder engagement with the potential of improving integration of care across a range of health and care providers involved in the pathway.

scholarly journals Early discharge planning in preterm low birth weight babies: A quality improvement project

2016 ◽  
Vol 26 (2) ◽  
pp. 98-101
Author(s):  
Amudha Jayanthi Anand ◽  
Mei Chien Chua ◽  
Siok Hong Khoo ◽  
Poh Leng Yuen ◽  
Mary Choi Wan Fong ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Birth Weight ◽  
Low Birth Weight ◽  
Phase 1 ◽  
Cost Savings ◽  
Early Discharge ◽  
Quality Improvement Project ◽  
Phase 2 ◽  
Low Birth Weight Infants ◽  
Improvement Project

Introduction: Extended hospitalization of low birth weight infants increases risk of medical and psychosocial complications. Our aim was to reduce the length of hospitalization and assess safety and cost savings of discharging infants at a weight of 1900 g instead of 2000 g, as has been the practice. Methods: This is a single-centre, nurse led quality improvement project done at a tertiary neonatal unit in Singapore with primary outcome of reducing average length of stay in selected low birth weight infants. In phase 1, infants with birth weight between 1000 and 1700 g were discharged at 1900 g, provided they met the discharge criteria. Interventions were introduced in phase 2 after interim analysis for the two most common causes for delayed discharge: poor bottling skills and waiting time for scheduled herniotomy. Results: In phase 1, the mean hospitalization stay was reduced by 5.5 days, with 21% of the babies discharged at 1900 g. The safety of the intervention was assessed by rehospitalization rates, and found to be negligible. Interventions introduced in phase 2 to address the two major causes of delayed discharge did not improve the outcome. The estimated cost savings for each subsidized patient after implementation of the interventions was S$340–1100 over the two phases. Conclusion: Though only 21% of eligible infants could be discharged early, the study helped us identify key areas of intervention to facilitate early discharge of preterm infants. These included improving babies’ sucking skills, planning for early surgery, and providing adequate parental training. Safety and cost savings appear to be promising as well.

scholarly journals Reducing the Time From Diagnosis to Treatment of Patients With Stage II/III Rectal Cancer at a Large Public Hospital

2016 ◽  
Vol 12 (2) ◽  
pp. e257-e262 ◽  
Author(s):  
Marc S. Hoffmann ◽  
Lori A. Leslie ◽  
Ryan W. Jacobs ◽  
Stefanos Millas ◽  
Venkateswar Surabhi ◽  
...  
Keyword(s):  
Rectal Cancer ◽  
Quality Improvement ◽  
Public Hospital ◽  
Cost Effective ◽  
Stage Ii ◽  
Curative Intent ◽  
Effective Interventions ◽  
High Staff Turnover ◽  
Standard Quality ◽  
Cancer Network

Curative-intent therapy for stage II/III rectal cancer is necessarily complex. Current guidelines by the National Comprehensive Cancer Network recommend preoperative concurrent chemoradiation followed by resection and additional adjuvant chemotherapy. We used standard quality improvement methodology to implement a cost-effective intervention that reduced the time from diagnosis to treatment of patients with stage II/III rectal cancer by approximately 30% in a large public hospital in Houston, Texas. Implementation of the program resulted in a reduction in time from pathologic diagnosis to treatment of 29% overall, from 62 to 44 days. These gains were cost neutral and resulted from improvements in scheduling and coordination of care alone. Our results suggest that: (1) quality improvement methodology can be successfully applied to multidisciplinary cancer care, (2) effective interventions can be cost neutral, and (3) effective strategies can overcome complexities such as having multiple sites of care, high staff turnover, and resource limitations.

scholarly journals Checklist to aid young physicians managing obstetric emergencies in rural India: a quality improvement initiative

2021 ◽  
Vol 10 (Suppl 1) ◽  
pp. e001435
Author(s):  
Varad Puntambekar ◽  
Aparna K Sharma ◽  
Kapil Yadav ◽  
Rakesh Kumar
Keyword(s):  
Quality Improvement ◽  
Physical Examination ◽  
Phase 1 ◽  
Clinical History ◽  
Rural India ◽  
Quality Improvement Initiative ◽  
Implementation Phase ◽  
Maximum Improvement ◽  
Data Points ◽  
Young Physicians

BackgroundThe decision to admit or refer a patient presenting with an obstetric emergency is extremely crucial. In rural India, such decisions are usually made by young physicians who are less experienced and often miss relevant data points required for appropriate decision making. In our setting, before the quality improvement (QI) initiative, this information was recorded on loose blank sheets (first information sheets (FIS)) where an initial clinical history, physical examination and investigations were recorded. The mean FIS completeness, at baseline, was 73.95% (1–5 January 2020) with none of the FIS being fully complete. Our objective was to increase the FIS completeness to >90% and to increase the number of FIS that were fully complete over a 9-month period.MethodsWith the help of a prioritisation matrix, the QI team decided to tackle the problem of incomplete FIS. The team then used fishbone analysis and identified that the main causes of incomplete FIS were that the interns did not know what to document and would often forget some data points. Change ideas to improve FIS completeness were implemented using Plan-Do-Study-Act (PDSA) cycles, and ultimately, a checklist (referred to as antenatal care (ANC) checklist) was implemented. The study was divided into six phases, and after every phase, a few FIS were conveniently sampled for completeness.ResultsFIS completeness improved to 86.34% (p<0.001) in the post implementation phase (1 Feb to 31 August 2020), and in this phase, 69.72% of the FIS were documented using the ANC checklist. The data points that saw the maximum improvement were relating to the physical examination.ConclusionThe use of ANC checklist increased FIS completeness. Interns with no prior clinical and QI experience can effectively lead and participate in QI initiatives. The ANC checklist is a scalable concept across similar healthcare settings in rural India.

Major reductions in unnecessary aspartate aminotransferase and blood urea nitrogen tests with a quality improvement initiative

2019 ◽  
Vol 28 (10) ◽  
pp. 809-816 ◽  
Author(s):  
Rachel Strauss ◽  
Alex Cressman ◽  
Mark Cheung ◽  
Adina Weinerman ◽  
Suzanne Waldman ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Blood Urea Nitrogen ◽  
Aspartate Aminotransferase ◽  
Cost Savings ◽  
Absolute Number ◽  
Choosing Wisely ◽  
Audit And Feedback ◽  
Quality Improvement Initiative ◽  
Urea Nitrogen ◽  
Hospital Days

Background/contextUnnecessary laboratory testing leads to considerable healthcare costs. Aspartate aminotransferase (AST), commonly ordered with alanine aminotransferase (ALT) and blood urea nitrogen (BUN), commonly ordered with creatinine (Cr), often add little value to patient management at significant cost. We undertook a choosing wisely based quality improvement initiative to reduce the frequency of testing.ObjectivesTo reduce the ratio of AST/ALT and BUN/Cr to less than 5% for all inpatient and outpatient test orders.MeasuresAbsolute number and ratio of AST/ALT and BUN/Cr; AST, ALT, BUN and Cr tests per 100 hospital days; projected annualised cost savings and monthly acute inpatient bed days.ImprovementsWe created guidelines for appropriate indications of AST and BUN testing, provided education with audit and feedback and removed AST and BUN from institutional order sets.Impact/resultsThe ratios of AST/ALT and BUN/Cr decreased significantly over the study period (0.37 to 0.14, 0.57 to 0.14, respectively), although the goal of 0.05 was not achieved due to a delay in adopting the choosing wisely strategies during the study time period by some inpatient units. The number of tests per 100 hospital days decreased from 20 to 7 AST (95% CI 19 to 20.5, 5.6 to 8.7, p<0.001) and from 72 to 17 BUN (95% CI 70 to 73.4, 16.6 to 22.9, p<0.001). The initiative resulted in a projected annualised cost savings of C$221 749.DiscussionA significant decrease in the AST/ALT and BUN/Cr ratios can be achieved with a multimodal approach and will result in substantial healthcare savings.

scholarly journals PRS44 COST SAVINGS AND REDUCED HOSPITALIZATIONS: A QUALITY IMPROVEMENT INITIATIVE

2019 ◽  
Vol 22 ◽  
pp. S357
Author(s):  
D. Trout ◽  
A.H. Bhansali ◽  
D.D. Riley ◽  
F. Peyerl ◽  
R. Nicksic ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Cost Savings ◽  
Quality Improvement Initiative

Reducing inappropriate rasburicase use to promote cost-effective care.

2018 ◽  
Vol 36 (30_suppl) ◽  
pp. 312-312
Author(s):  
Arjun Gupta ◽  
Komal Patel ◽  
Taylor Roberts ◽  
Eileen M. Marley ◽  
Hsiao Ching Li ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Best Practice ◽  
Tumor Lysis Syndrome ◽  
Kidney Injury ◽  
Cost Savings ◽  
Cost Effective ◽  
Baseline Period ◽  
Hospital System ◽  
Effective Interventions ◽  
Quality Improvement Interventions

312 Background: Rasburicase is recommended for treating established Tumor lysis syndrome (TLS) and patients at high-risk for TLS. Unfortunately, it is an expensive medication and unnecessary use contributes to expenses. Methods: A multidisciplinary quality improvement team reviewed the process of ordering rasburicase and its prescription patterns at Parkland Heath and Hospital System, Dallas, TX between 10/2015-9/2017. Use was determined as appropriate/ inappropriate based on internally approved indications (laboratory TLS, at-risk for TLS, acute kidney injury and hyperuricemia, failure of or inability to administer allopurinol). Quality improvement interventions were implemented based on weaknesses identified. Results: 65 doses of rasburicase were administered during the 2-year baseline period; 21 (32.3%) of these were grossly inappropriate. The most common ordering providers were oncologists (23 orders, 35%), hospitalists (16 orders, 25%), intensivists (11 orders, 17%), and emergency physicians (8 orders, 12%). Ordering process review identified several pitfalls: one-click ready to sign order, auto-population of dosage, no hard-stop requiring providers to review rasburicase indications, and no pharmacy oversight. We aimed to reduce the percentage of inappropriate rasburicase orders from a baseline of 32.3% to 10% over 3 months. In 2/2018, we implemented PDSA cycle 1 including introducing a best practice advisory requiring providers to select an approved indication for medication use and changed auto-population of rasburicase dosage to 3 mg. A mandatory secondary review by pharmacy prior to dispensing the medication was implemented. Over a 3-month period post-change (2/2018- 5/2018), 11 of 11 rasburicase administered doses have been appropriate (0% inappropriate). Conclusions: A multidisciplinary team and classic quality improvement methodology was able to reduce inappropriate rasburicase use from 32.3% to 0%, with significant cost savings. Straightforward electronic medical record interventions and increased pharmacy oversight are effective interventions in curbing medication overuse. We will periodically re-assess utilization patterns and refine PDSA cycles as needed.

The sustainability of a quality improvement initiative

2020 ◽  
Vol 33 (5) ◽  
pp. 195-199
Author(s):  
Veronica Belostotsky ◽  
Catherine Laing ◽  
Deborah E. White
Keyword(s):  
Quality Improvement ◽  
Elderly Population ◽  
Functional Decline ◽  
Cost Effective ◽  
The Elderly ◽  
Primary Objective ◽  
Quality Improvement Initiative ◽  
Cross Sectional ◽  
One Year

Functional decline in seniors admitted to hospital is due in part to lack of mobilization. Many Quality Improvement (QI) initiatives targeting mobilization of the elderly population in acute care exist; however, their long-term effectiveness is not well-documented. Mobilization of Vulnerable Elders (MOVE) was a grant-funded initiative that started in Ontario and spread to Alberta. The primary objective of this project was to ascertain the sustainability of the MOVE project 1 year post implementation at two hospital sites in Alberta, Canada. Qualitative and quantitative cross-sectional data were gathered from multidisciplinary healthcare professionals. Our findings suggest MOVE was not well-sustained one year post implementation. Examination of specific survey questions provided an indication of strengths and weaknesses of the MOVE QI. Sustainable and cost-effective QI targeted at this elderly patient demographic could alleviate some of the demand on the healthcare system. Modifications to improve the sustainability of MOVE are summarized.

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