Initiative to Improve Evidence-Based Chronic Obstructive Pulmonary Disease Hospitalist Care Using a Novel On-Line Gamification Patient Simulation Tool: A Prospective Study.

Chronic obstructive pulmonary disease (COPD) remains a leading cause of morbidity and mortality. Much of the disease burden comes from exacerbations requiring hospitalization. Unwarranted care variation and divergence from evidence-based COPD management guidelines among hospitalists is a leading driver of the poor outcomes and excess costs associated with COPD-related hospitalizations. We engaged with Novant Health hospitalists to determine if measurement and feedback using fixed-choice simulated patients improves evidence-based care delivery and reduces costs. We created a series of gamified acute-care COPD case simulations with real-time feedback over 16 weeks then performed a year-over-year analytic comparison of the cost, length of stay (LOS), and revisits over the six months prior to the introduction of the simulated patients, the four months while caring for the simulated patients, and the six months after. In total, 245 hospitalists from 15 facilities at Novant Health participated. At baseline, the overall quality-of-care was measured as 58.4% + 12.3%, with providers correctly identifying COPD exacerbation in 92.4% of cases but only identifying the grade and group in 61.9% and 49.5% of cases, respectively. By the study end, the quality-of-care had improved 10.5% (p < 0.001), including improvements in identifying the grade (+9.7%, p = 0.044) and group (+8.4%, p = 0.098). These improvements correlated with changes in real-world performance data, including a 19% reduction in COPD-related pharmacy costs. Overall, the annualized impact of COPD improvements led to 233 fewer inpatient days, 371 fewer revisit days, and inpatient savings totaling nearly $1 million. Engaging practicing providers with patient simulation-based serial measurements and gamified evidence-based feedback potentially reduces inpatient costs while simultaneously reducing patient LOS and revisit rates.

A Direct Comparison of the Clinical Practice Patterns of Advanced Practice Providers and Doctors.

BACKGROUND: Rising health care costs, physician shortages, and an aging patient population have increased the demand and utilization of advanced practice providers (APPs). Despite their expanding role in care delivery, little research has evaluated the care delivered by APPs compared with physicians. METHODS: We used clinical patient simulations to measure and compare the clinical care offered by APPs and physicians, collecting data from 4 distinct health care systems/hospitals in the United States between 2013 and 2017. Specialties ranged from primary care to hospital medicine and oncology. Primary study outcomes were to 1) measure any differences in practice patterns between APPs and physicians, and 2) determine whether the use of serial measurement and feedback could mitigate any such differences. RESULTS: At baseline, we found no major differences in overall performance of APPs compared with physicians (P = .337). APPs performed 3.2% better in history taking (P = .013) and made 10.5% fewer unnecessary referrals (P = .025), whereas physicians ordered 17.6% fewer low-value tests per case (P = .042). Regardless of specialty or site, after 4 rounds of serial measurement and provider-specific feedback, APPs and physicians had similar increases in average overall scores-7.4% and 7.6%, respectively (P < .001 for both). Not only did both groups improve, but practice differences between the groups disappeared, leading to a 9.1% decrease in overall practice variation. CONCLUSIONS: We found only modest differences in quality of care provided by APPs and physicians. Importantly, both groups improved their performance with serial measurement and feedback so that after 4 rounds, the original differences were mitigated entirely and overall variation significantly reduced. Our data suggest that APPs can provide high quality care in multiple clinical settings.

A Quality Collaboration in Heart Failure and Pneumonia Inpatient Care at Novant Health: Standardizing Hospitalist Practices to Improve Patient Care and System Performance.

BACKGROUND: Heart failure and pneumonia are among the most measured and expensive conditions to treat in the United States across all payer types and are top of mind for value-driven hospital organizations and payers seeking to not only improve the quality of care for patients but also reduce unnecessary spending. Care standardization potentially leads to better patient outcomes and reduced excess costs but is a difficult objective to achieve. METHODS: A pre-post analysis of clinical practice, patient outcomes, and cost was designed to determine if serial measurement and feedback using simulated patients improves patient care quality and reduces costs for two common conditions cared for by hospitalists: pneumonia and heart failure. Care decisions measured using the simulations were compared to patient-level data collected by the system. RESULTS: Intrafacility care variation seen among Novant Health's 11 facilities employing hospitalists decreased from 14.9% to 8.5%, and overall quality-of-care scores by individual providers improved by 14.6 percentage points from study start to end. Overall, care changes (for example, troponin usage, palliative care consults, beta blocker orders) documented in the simulated patients matched the available patient-level data. Care standardization around evidence-based practices, as measured by the simulations, was associated with appreciable decreases in patient length of stay and readmissions, amounting to nearly $1.1 million in savings for Novant Health. CONCLUSION: An approach using simulated patients that includes serial measurement and feedback may help significantly reduce practice variation between different facilities in a health system and reduce costs substantially without negatively affecting outcomes.