Doing Better, Spending Less

The 37-year-old man was admitted to Allegheny General Hospital (AGH) in Pittsburgh, Pennsylvania, for pancreatitis — an inflammation of the pancreas, in this case caused by fat particles circulating in the man’s blood. Treatment seemed to be going well until four days into his stay. That’s when staff discovered that the plastic line attached to the catheter delivering medicine and fluids through the patient’s femoral vein was contaminated. Undetected, bacteria had traveled into his body and flourished, creating a massive infection that antibiotics couldn’t quell. Abscesses developed in the man’s abdomen, one after another, despite repeated surgeries to drain the infected tissue. It wasn’t clear that the patient would live. “He spent 87 days in the hospital,” says Richard P. Shannon, MD, Chairman of AGH’s Department of Medicine. “He survived but his health will never be the same.”
Protecting patients from harm is the main reason to provide the best possible care every time, says Shannon. “We should always live up to patients’ expectation that even when we’re not able to cure them, we will never, ever hurt them.” But there’s another good reason to deliver top quality care, he says, one that health professionals don’t often acknowledge. The Centers for Disease Control and Prevention (CDC) estimates that hospital-acquired infections add $5 billion a year to the nation’s health care bill, even while the need to spend wisely — to cover the uninsured, expand preventive services, and provide the drugs that keep people from getting sick in the first place — grows more urgent by the day. The cost of the hospitalization for the patient who developed a massive infection was $241,000, says Shannon. Without the infection, it would have been less than $6,000.
Dr. Shannon was aiming to save lives, not necessarily money, in 2003 when he convinced his 530-bed teaching hospital to invest $35,000 in a program to reduce the incidence of two potentially lethal infections. His targets were catheter-related bloodstream infections (CRBLIs), such as the one that attacked the patient with pancreatitis, and the ventilator-associated pneumonias (VAPs) that threaten patients on mechanical ventilators when their breathing tubes become contaminated. Eliminating VAPs and CRBLIs are the focus of two of the six interventions in the 100,000 Lives Campaign sponsored by the Institute for Healthcare Improvement (IHI). To improve the safe handling of catheters and breathing tubes, AGH redesigned its delivery of care and implemented new protocols to limit patients’ exposure to pathogens. The results were startling. Within a year, the hospital’s rate of CRBLIs had plunged by 87 percent and VAPs had dropped by 83 percent.
It was relatively easy to get nurses and residents to embrace unfamiliar techniques, says Shannon, because they work at patients’ bedsides. “We estimate that our efforts probably saved 47 lives. Once the staff saw we could have that kind of impact, they were immediately on board.” Persuading the executive suite to finance the new strategies can be more daunting, says Shannon. “Their job is to look at costs, but they don’t get to see the consequences of poor quality care case by case. They see aggregated data, which blunts the financial impact.”
In the case of the patient who developed multiple complications from his catheter infection, for example, “The insurer paid 33 times more than it would have for the pancreatic disease alone, but the extra revenue still didn’t cover all the expenses of treating him,” says Shannon. “The hospital had to absorb more than $41,000 on that one case.” Shannon realized that a loss that large could be an eye-opener to his hospital’s senior leaders, so he asked to see the financial records of each AGH patient who had developed a CRBLI or VAP in the previous two years. He then analyzed the numbers to calculate the extra costs generated solely by the infection. “We found that in each case 30 to 70 percent of the total went for treating the infection or the complications it caused,” he says.
That meant that AGH’s sharp reduction in infections represented more than $2.2 million in savings for the hospital, a figure that impressed not only administrators but AGH’s main insurer, who provided a $2.1 million incentive bonus to keep up the good work. “The total return on the initial $35,000 investment was $4.3 million,” says Shannon, who received $1.5 million of that to expand AGH’s efforts with additional staff and training.
Though unusually candid in its openness about realizing financial savings by improving care, AGH isn’t unique in its ability to do so through infection reduction. Success stories abound among the more than 2,900 hospitals involved in IHI’s 100,000 Lives Campaign, which includes AGH. 
Swedish Hospital Medical Center, the Pacific Northwest’s largest hospital, with 1,300 beds on three campuses in the greater Seattle, Washington, area, used to average two or three VAPs per month in its 80-bed intensive care units (ICUs). After June Altaras, RN, BSN, the Clinical Manager of Adult ICUs, attended an IHI Breakthrough Series Collaborative on Reducing Complications from Ventilators and Central Lines in the ICU with members of her staff in 2004, VAPs at Swedish dropped sharply. Between October 2004 and September 2005, the hospital had just five VAPs — 18 fewer than during the same period a year earlier. Based on CDC estimates that the average VAP adds $40,000 to the cost of care, Swedish avoided spending $720,000.
Swedish Hospital invested $81,000 in the IHI training, says Altaras, and the administration agreed to send staff to one more Collaborative next year. However, “when the board saw the cost savings, they decided we could send staff to two more Collaboratives.” Next time, says Altaras, “I’m going to ask them to add a percent of the savings to our budget.”
Other infection-reduction efforts with enviable results include the following:
  • Overlake Hospital Medical Center in Bellevue, Washington, which reduced VAPs by 80 percent and CRBLIs by 74 percent, avoiding “needless harm” to 39 patients, says the hospital, and saving an estimated  $1.8 million over 12 months (October 2004 to September 2005).
  • Keystone: ICU — a consortium of 127 ICUs in 70 hospitals in Michigan, California, Iowa, and Indiana — which reduced CRBLIs by nearly 50 percent between March 2004 and June 2005. Sixty-eight of the participating ICUs completely eliminated VAPs or CRBLIs for six months or more. Based on projections from the Johns Hopkins University Quality and Safety Research Group, a partner in the venture, the improvements saved more than 1,500 lives, 81,000 hospital days, and $165 million. Most of the hospitals in the Keystone: ICU initiative are taking part in IHI’s 100,000 Lives Campaign.
The idea that improving health care quality can save money may take some getting used to, says David Calkins, MD, a senior fellow at IHI who oversees the intervention protocols of the 100,000 Lives Campaign. “Most patients are convinced that good care is more expensive than poor care, when the opposite is actually true.” At the same time, says Calkins, physicians sometimes resist following evidence-based guidelines, a requisite of cost-effective care, feeling that they take the art out of medicine. So it’s not surprising, he says, if health care administrators don’t focus much on the financial advantages of quality improvement either. The best catalyst for attitude change, says Calkins, may be the burgeoning movement to capture and report performance data.
Allegheny General Hospital’s Dr. Richard Shannon couldn’t agree more. “The appropriate infection rate is zero.” And Shannon would go a step further. Providers — including himself — should only be paid for good quality care, never for bad, he says. “Right now, we all get paid for whatever we do, good or bad. That’s the wrong incentive.” Even if payment isn’t tied to performance for years to come, says David Calkins, “Once everyone understands the real human cost of poor quality care, the financial cost will come into focus, too.” In any event, he says, “That train is leaving the station. Get aboard or get left behind.”​
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