"While MRI and CT remain indispensable technologies to diagnose many medical conditions, dramatic advances in ultrasound image quality have greatly expanded its role at the bedside, as hospitals are providing smarter, safer and more cost-efficient care through selecting the right test for the right patient at the right time."
Every day, more than 1,000 patients die because of preventable hospital errors, according to the Leapfrog Group's latest Hospital Safety Score report, released in October 2014. That means hospital errors now rank as the third leading killer of Americans, after heart disease and cancer.
The Patient Protection and Affordable Care Act, however, has given hospitals a powerful new incentive to reduce medical harm and provide safer care. Fiscal year 2015 marks the first year in which poorly performing hospitals face penalties under three pay-for-performance programs established by the PPACA: the Readmissions Reduction Program, Value-Based Purchasing and the new Hospital-Acquired Condition Reduction Program.
Financial pressure from these penalty programs, which collectively put 5.5 percent of inpatient reimbursements at risk, are already spurring measurable improvements in patient safety. Between April and October 2014, according to the Leapfrog report, many of the 2,520 hospitals evaluated demonstrated significant progress in adopting certain safety practices. However, 41 percent of the hospitals received poor scores for outcomes, suggesting that they need to work harder to reduce medical harm — and avoid sanctions under P4P programs.
Here are four important ways in which the new HAC Reduction Program, which took effect in October 2014, could significantly improve the safety and quality of care for the 35.1 million Americans who are hospitalized each year, not just those covered by Medicare.
1. A greater focus on evidence-based medical care
Not only is healthcare reform helping to advance patient safety, but it has also accelerated collaboration between medical specialties to promote broad acceptance of evidence-based policies and clinical guidelines, such as optimal use of medical imaging.
In a 2013 policy statement published in Annals of Internal Medicine, colleagues and I presented consensus recommendations based on guidelines from the American College of Emergency Physicians and the American College of Radiology on appropriate use of CT scans to further ensure that these imaging studies are medically indicated as part of "patient-centered" care.
Concerns have been raised about increased exposure to ionizing radiation from medical imaging. The 2009 paper "Ionizing Radiation Exposure of the Population of the United States" reported that, in 2006, Americans were exposed to seven times as much ionizing radiation from medical procedures as they were in the early 1980s, mostly due to higher use of CT scans and nuclear medicine.
Of the approximately 80 million CT scans performed in the U.S. annually, about one-third are in the emergency setting. The consensus recommendations encourage emergency physicians to choose the imaging modality that is fastest, safest and most likely to immediately affect care. The goal of the recommendations is to reduce use of CT scans when medically appropriate by using imaging methods that don't expose patients to ionizing radiation, such as ultrasound.
For example, it's becoming increasingly common for adults and children to be evaluated in the emergency department for flank pain that may be caused by kidney stones, a problem that now affects nearly nine percent of the population. Since this condition tends to recur, rather than expose patients with a history of kidney stones to repeated CT scans, the preferred practice is to use ultrasound at the bedside as the first diagnostic test, an approach supported by guidelines from both ACEP and ACR.
A recent randomized study published in New England Journal of Medicine compared outcomes in 2,759 emergency department patients who were checked for suspected kidney stones with ultrasound or CT. The ultrasound group had shorter emergency department stays and lower hospital costs, with no significant differences in risk of subsequent serious adverse events, pain scores, return emergency department visits, or hospitalizations, compared to the CT group. Based on these findings, lead study author Rebecca Smith-Bindman, MD, of the University of California, San Fransciso, recommends that, "ultrasonography should be used as the first diagnostic imaging test, with further imaging studies performed at the discretion of the physician."
2. New $330 million penalties for medical errors
Since October 2014, hospitals scoring in the top quartile for certain HACs have their Medicare reimbursements cut by 1 percent. The new sanctions are expected to total an estimated $330 million in FY 2015, with a preliminary assessment by CMS suggesting that on average, each penalized hospital could be docked nearly $434,000. However, large hospital systems could face much worse financial setbacks, with an analysis by the Advisory Board Group estimating the single largest HAC loss to total more than $1.6 million.
Penalties will be levied based on the hospital's HAC score, which is calculated on a scale of one to 10, depending on its rate of infections and eight other serious but potentially preventable complications, including iatrogenic pneumothorax (accidental puncture and collapse of the patient's lung) during medical treatments, such as central venous catheterization. In Medicare's preliminary assessment, hospitals scoring above seven would incur the penalty.
This pay-for-performance policy is designed to transform hospital care by providing a potent incentive to curb medical errors and their associated costs. That could offer a potentially lifesaving benefit for patients. In 1999, the Institute of Medicine shocked the world by reporting that hospital mistakes kill up to 98,000 Americans a year, a rate of medical harm equivalent to four jumbo jets crashing every week.
An alarming 2013 study, however, suggests that the toll may actually be far higher, with an estimated 210,000 to 440,000 patients suffering preventable harm in the hospital each year that contributes to their deaths. The study, published in Journal of Patient Safety, found that 14 to 21 percent of hospital patients fall victim to medical mistakes, while 0.60 to 1.4 percent suffer fatal harm. These findings were based on four recent studies in which patients' medical records were checked for possible adverse events using a screening method called the Global Trigger Tool.
3. New rewards and incentives for hospitals to deliver better care
Another P4P program, VBP, which took effect in October 2012, uses a carrot-and-stick approach to improve hospital performance and patient safety, with hospitals that score highly on a variety of quality measures rewarded with rises in their Medicare payments, while those with poor scores are penalized with cuts.
"The Affordable Care Act gave CMS many new tools to convert Medicare from a program that paid for decades on automatic pilot into one that deliberately pays to promote better health," CMS Chief Medical Officer Dr. Patrick Conway explained in a recent blog post.
Since the revenue-neutral program is funded by extracting money from poorly performing hospitals and giving it to the best performers, it provides powerful motivation for hospitals to consistently follow proven safety practices to reduce medical errors and improve outcomes.
For example, many leading hospitals, including Wilmington, Del.-based Christiana Care Health System, where I practice, have now adopted ultrasound guidance as a best practice for inserting central venous lines, a procedure performed more than 5 million a year in U.S. hospitals, with complication rates of more than 15 percent reported in medical literature.
Medicare has added one especially dangerous — or even potentially fatal — adverse event, iatrogenic pneumothorax during central line placement, to its HAC list. Along with putting patients in peril, the mistake can also hike hospital costs by up to $45,000 per incident, according to a study by the Agency for Healthcare Quality and Research.
Many excellent studies show that ultrasound guidance can powerfully improve the safety and success of this very common procedure. In fact, in one randomized study of 900 critical care patients, use of ultrasound visualization reduced the rate of collapsed lung during central line placement to zero compared to 2.4 percent for blind placement.
The study also reported that ultrasound guidance took less time, had significantly lower rates of several other dangerous complications, and was more likely to succeed on the first try, so patients weren't jabbed repeatedly in the neck. Faster care is particularly crucial in the emergency department, where seconds can literally make a life-or-death difference.
The reason is simple: Just as it would be easier — and safer — to use a flashlight to find your fuse box during a nighttime power outage compared to trying to navigate through your home in the dark without bumping into the furniture, ultrasound visualization lets doctors see the blood vessel they are targeting, and avoid injuring nearby nerves and tissues.
There is also very good data suggesting that ultrasound guidance at the bedside can improve the safety, comfort and first-pass success of other needle-based procedures, such as draining fluid from the chest, belly or joints; regional nerve block injections; and inserting peripheral IV lines.
4. Smart, FAST and cost-effective emergency care
About 50 percent of hospital patients get their initial care in the emergency department, where using ultrasound at the bedside as the first diagnostic test helps save both money and lives.
Recently, my team saw a patient who had been in a car accident the previous day. He had no obvious external injuries and his vital signs were normal. However, he had mild abdominal tenderness and reported that he was taking blood-thinners for a cardiac condition.
We immediately performed a FAST (Focused Assessment with Sonography in Trauma) exam, a well-established test to check trauma patients for potentially life-threatening internal injuries. The test revealed free fluid in the man's abdomen, typically a sign of hemorrhage in a trauma patient. Further evaluation confirmed severe bleeding in his spleen.
Within minutes, the patient was given a minimally invasive embolization procedure to halt the hemorrhage. Without ultrasound at the bedside and a FAST exam to rapidly make the right diagnosis, followed by prompt treatment, this man would have died.
This test has become an enormously important tool in emergency medicine, given that 38 million patients a year are evaluated in emergency departments for trauma, which ranks as the top cause of death in patients under age 45.
In a recent randomized study, patients with torso trauma who were evaluated with point-of-care limited ultrasonography (PLUS) received swifter care, with an average time from arrival at the emergency department to operative care of 57 minutes, compared to an average time of 116 minutes for a control group of torso trauma patients who weren't assessed with PLUS.
Initial evaluation with ultrasound, combined with faster treatment, paid off in several other ways for the PLUS patients, including:
- Shorter hospital stays — an average of 6.2 days versus 10.2 days for the control group.
- Fewer complications and CT scans.
- Lower medical bills — an average of $28,400 for PLUS patients who were treated surgically compared to $47,600 for patients in the control group.
Another major benefit of ultrasound visualization is that it spares patients the hazards of radiation exposure associated with CT scans, including increased risk for cancer. A study by the Joint Commission recently estimated that the 72 million CT scans performed in the U.S. in 2007 might trigger 29,000 future cancers and contribute to 14,500 deaths.
While MRI and CT remain indispensable technologies to diagnose many medical conditions, dramatic advances in ultrasound image quality have greatly expanded its role at the bedside, as hospitals are providing smarter, safer and more cost-efficient care through selecting the right test for the right patient at the right time.
Paul R. Sierzenski, MD, RDMS, FACEP is the Director of Emergency, Trauma and Critical Care Ultrasound for Christiana Care Health System's Department of Emergency Medicine. He is also the Chair, Government Policy & Public Relations for the American College of Emergency Physicians Ultrasound Section and a Master's Candidate in Health Quality and Safety at the Jefferson School of Population Health.