An emerging category of hospital quality initiatives, comparable to preventing medical errors and improving quality and patient safety, could be labeled “waste management” or “waste reduction.” "Waste" in this sense refers not to biohazardous substances in need of disposal, but to the overuse of medical resources—such as lab tests and pharmaceuticals—when they are not helpful to a patient's medical management.
This will be a growing focus for hospitalists, says Robert Wachter, MD, MHM, chief of the division of hospital medicine at the University of California at San Francisco (UCSF) Medical Center, and author of the HM-focused blog, Wachter's World.
"If patients are getting CAT scans they don't really need or an extra day of telemetry because we don't have criteria for who should be on telemetry, that's wasteful, it's costly, and it could be dangerous,” Dr. Wachter explained at the UCSF Management of the Hospitalized Patient meeting last October. "The data are clear that 30% of what we do in American medicine is of no value to patients—and some substantial portion of that is harmful as well. I think we as hospitalists should be identifying what these wasteful things are—and making the hard decisions to stop them."
In an academic setting such as UCSF, many of the hospitalists lead quality, safety, and "waste reduction" projects, which often use similar tools and methods but have a different focus. Dr. Wachter's colleague Niraj Sehgal, MD, MPH, the department of medicine's associate chair for quality improvement (QI) and patient safety, says that process-improvement tools such as Six Sigma and Lean methodologies can put unnecessary variation and waste under the microscope. But at UCSF, these efforts start with just looking at the data, then sharing the data with trainees and faculty.
"Clearly, attention is growing to this issue," Dr. Sehgal says. "We often talk about generating value in healthcare where value equals quality divided by cost, but we need to include the concept of appropriateness in that equation as well."
A radiology utilization awareness project at UCSF is looking at whether cost and radiation exposure information might influence the ordering of five common radiologic tests that together generate annual charges of nearly $10 million at UCSF's Moffitt-Long Medical Service. The project uses a number of educational strategies to encourage providers to think about whether the tests will change their clinical management.
"The preliminary data suggest that simply providing the cost and utilization data decreased utilization for three of the five tests evaluated," Dr. Sehgal says.
Physicians didn't necessarily ignore inefficiency and overuse in the past, he adds, but healthcare reform offers new opportunities to leverage greater cost consciousness in medical education and practice. "We're not having to convince our trainees and faculty that cost is important," he says. "They just don't always see the costs involved."