How Establishing Cardiovascular Care Standards Can Help to Improve Patient Outcomes

The idea of medical care variation refers to unwarranted deviation from a shared and deliberate approach to medical care delivery.¹ In 2009, the World Health Organization published the Surgical Safety Checklist as part of its “Safe Surgery Saves Lives” campaign.² This checklist was adapted from the field of aviation, where checklist usage is standard practice, and represents one of the most obvious examples of an effort to eliminate care variation in medicine today.

The primary goals of reducing care variation include (1) increasing patient safety through promoting efficient standardized care delivery, leading to greater reliability, and (2) the prevention of waste. Increased patient safety and adherence to established care standards have been demonstrated to produce better outcomes while reducing costs.¹ It is important to distinguish between unwarranted deviations from established standards of care and the need to tailor a specific treatment plan to a specific patient. Importantly, the former typically results from either a lack of accepted standards of care or an inability to consistently apply a certain standard in practice.

Cardiovascular care is an excellent example of an area where reducing and ultimately eliminating care variations can result in large positive impacts on several aspects of care delivery.

Costs

Successfully saving money does not merely rely on making more. Cost savings allow hospitals and providers to expand access to care while investing in better technology and improved treatments. Looking at coronary artery bypass grafting alone, the Advisory Board (Washington DC, USA) estimates a savings, per case, of $3,428 between hospitals in the 70^th and 30^th percentiles, respectively.¹ With regard to nonsurgical cardiovascular care, it has been estimated that five to eight million patients are seen for chest pain in emergency departments each year, while only about one-fourth end up being diagnosed with an acute coronary syndrome. The American College of Cardiologists (ACC) has estimated an annual savings of $189,000 per institution could be achieved by reducing the length of stay for chest pain–related observation by nine hours. Furthermore, by employing diagnostic standardization across the board for all presenting cardiovascular complaints and by reducing observation times from the 100^th percentile to the 20^th, the ACC estimates annual cost reductions approaching $400,000 could be realized.³

Outcomes

In 2018, Grahm et al. found that implementing decision support tools aimed at reducing care variations led to improvements in the consistency of health care delivery, increases in patient knowledge and engagement, and the avoidance of specific therapeutic interventions in patients who would receive no benefit from such.⁴ Cook et al. determined that unwarranted variations were associated with suboptimal outcomes as well as increased costs for the same outcome.⁵ They further observed that standardized, evidence-based care has many benefits, including reductions in unnecessary readmissions, lower rates of hospital-acquired infections, greater patient safety, and improved patient outcomes and satisfaction levels.⁵

The Advisory Board recognizes that there are barriers to reducing and even eliminating cardiovascular care variations and have laid the groundwork for success with four tools or techniques geared toward facilitating standardization and compliance with established care models. These four items are presented in more detail below:

Prioritize care variation reduction opportunities

The board has suggested that prioritizing variation reduction opportunities can be achieved by adopting a data-driven approach to uncovering examples of variations in clinical practice. Employing input across disciplines will further enable the selection of variations to target. One example might be developing standardized criteria for the application of computed tomography imaging in the emergency department. More efficient use of this technology may reduce costs while improving outcomes in patients who would benefit from the examination.

Engage physicians

Physicians are on the front lines in medicine. Designing processes for sharing performance data and providing incentive structures that reward physicians for their involvement can promote standardization design and engagement.

Design and embed care standards

The clinical workflow should dictate the implementation of standards to reduce unwarranted care variation. Easy opportunities for standardization may include using one electrocardiogram (ECG) solution institution-wide. Having one cart with the same ECG monitor utilizing the most advanced algorithm allows for standardized cardiovascular monitoring integration so that, when patients move from one unit to the next, the same equipment is utilized to ensure a more accurate representation of the patient’s status. This also removes the need for training across several systems, reducing opportunities for error.

Measure results and revise strategies

Once implemented, care standards must be regularly examined and revised as service line operations change. Data collection and reevaluation procedures should be a part of the process for long-term cardiovascular performance improvement.

Evidence supporting the standardization and reduction of variation exists in the current literature. Rowlandson et al. examined current computer-based ECG algorithms and found that clinically small but statistically significant differences exist between them, representing a source of unwarranted variation in cardiovascular care.⁶ Rowlandson, in other work, found that using an extensively tested ECG solution like the EK-Pro algorithm may help you prevent significant errors and improve the detection of cardiac events that might otherwise go unnoticed.⁷

A very recent study conducted by Edvinsson et al. looked at how the implementation of a standardized plan for the clinical management of adults with decompensated heart failure would impact care outcomes. They found that the development and introduction of a standard plan involving chronic heart failure guidelines and the best practices of clinical care with a team approach provoked a significant improvement in one-year mortality, 30-day readmission rates, and adherence to medication guidelines.⁸

In conclusion, clinicians, hospitals, and patients have a lot to gain through the reduction of cardiovascular care variation. Through cost reduction, workflow efficiency, and evidence-based standardization, we can create a more affordable and sustainable health care system where patients receive the right care at the right time, leading to better clinical and fiscal outcomes.

References

1. The Advisory Board. Playbook for reducing CV care variation: implementing effective care standards. Available at: https://www.advisory.com/research/cardiovascular-roundtable/research-reports/2018/playbook-for-reducing-cv-care-variation Accessed July 2, 2019.
2. Pugel AE, Simianu VV, Flum DR, Patchen Dellinger E. Use of the surgical safety checklist to improve communication and reduce complications. J Infect Public Health. 2015;8(3):219–225. DOI: 10.1016/j.jiph.2015.01.001. Accessed July 2, 2019.
3. American College of Cardiology Webinar 2017.
4. Graham MM, James MT, Spertus JA. Decision support tools: realizing the potential to improve quality of care. Can J Cardiol. 2018;34(7):821– DOI: 10.1016/j.cjca.2018.02.029. Accessed July 2, 2019.
5. Cook DA, Pencille LJ, Dupras DM, Linderbaum JA, Pankratz VS, Wilkinson JM. Practice variation and practice guidelines: attitudes of generalist and specialist physicians, nurse practitioners, and physician assistants. PLoS ONE. 2018;13(1):e0191943. DOI: 10.1371/journal.pone.0191943. Accessed July 2, 2019.
6. Kligfield P, Badilini F, Denjoy I, et al. Comparison of automated interval measurements by widely used algorithms in digital electrocardiographs. Am Heart J.2018;200:1– DOI: 10.1016/j.ahj.2018.02.014. Accessed July 2, 2019.
7. Mirvis DM, Berson AS, Goldberger AL, et al. Instrumentation and practice standards for electrocardiographic monitoring in special care units. A report for health professionals by a Task Force of the Council on Clinical Cardiology. 1989;79(2):464–471. DOI: 10.1161/01.CIR.79.2.464. Accessed July 2, 2019.
8. Edvinsson ML, Stenberg A, Åström-Olsson K. Improved outcome with standardized plan for clinical management of acute decompensated chronic heart failure. J Geriatr Cardiol. 2019;16(1):12–18. DOI: 10.11909/j.issn.1671-5411.2019.01.002. Accessed July 2, 2019.