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Finding the Right Path

Patients may love the idea of care that is tailored to their personal needs, but is that always in their best interest? Standardized approaches enhance the quality of care and cut down on waste.

  Benefits of Early Mobilization  
  Graphic: Courtesy of Dr. Nancy McLaughlin

By Dan Gordon • Illustration by Vigg • Photography by Ann Johansson

Given the strong current of rugged individualism that always has run through American culture, it’s not surprising that we, as healthcare consumers, want, and expect, treatment plans that are tailored to our unique biology and circumstances. But is purely personalized care always the best medicine?
Despite strong evidence on the benefits of cholesterol-lowering statin medications for patients with certain cardiovascular-disease risk factors, there is considerable variation in which patients are prescribed the drugs — with physician preferences and geography often carrying more weight than data from large randomized controlled trials, which are considered the gold standard for clinical research. Similarly, the research is unequivocal on the benefits of administering certain antibiotics at key points before specific operations, yet it isn’t always done.

And if the evidence points to the value of colonoscopy screening in normal-risk patients beginning at age 50, we don’t expect our doctor to decide on a case-by-case basis whether or not to recommend it.

In other words, even as many people like to romanticize medicine as something of an art, in which decisions about treatment are made creatively and individually, that is not really what we want in cases where the science clearly points to a single approach as most effective. Then, we’d prefer to go by the book.

“Intuitively, we want care that is patient-specific. But in reality, patients are much-more similar than they are different,” says Tom Rosenthal, MD, chief administrative officer for UCLA Health. “When care is purely individualized, we find a lot of variation that isn’t explainable by the evidence and isn’t in the patient’s best interest.” In addition, there is “variation that is not based on necessity and therefore arguably wasteful. By standardizing the appropriate aspects of care and setting up processes to ensure that they are delivered reliably, we reduce that random variation. In so doing, we improve quality while reducing cost.”

Standardization makes for a more-consistent product, adds Samuel A. Skootsky, MD (RES ’82, FEL ’83), chief medical officer of the UCLA Faculty Practice and Medical Group, which oversees the outpatient practices of UCLA Health. That, “almost by definition, means higher quality. Particularly when patients are engaged to help define the standardized-care pathways, it’s more likely to result in the outcomes that they want,” he says.

Although evidence points to the need for more standardization as a way to improve the safety and efficiency of care, no one is advocating a checklist approach to all aspects of medicine: Some individual physician discretion will always have its place. Moreover, Dr. Skootsky is quick to point out that within most standardized pathways, there will be exceptions. “A particular patient may come along for whom the standardized approach is not in his or her best interest,” he says. “In such cases, you can’t be dogmatic. Instead, it’s an opportunity to learn, then see if this is a situation that should be built into the approach for the future.”

STANDARDIZATION ALSO DOESN’T NECESSARILY MEAN one set of rules for all patients. “A patient with a brain tumor can be a 16-year-old girl who is otherwise perfectly healthy, or it could be a 78-year-old man with cardiac and pulmonary disease and diabetes. Obviously, those two very different patients, with the same diagnosis, will require different patterns of treatment,” says Neil Martin, MD, chair of neurosurgery at the David Geffen School of Medicine at UCLA. “The goal is to make sure we are reliably providing the best-possible care at the right time for every disease process. We don’t want to rigidly standardize, but we want to eliminate variation that is non-scientific and based on individual physician preference.”

Dr. Martin’s department is in the process of systematically evaluating every step of treatment for patients with particular conditions to define the best approaches and ensure that they are applied in all cases. The effort involves weighing the existing scientific evidence and collecting input from all personnel involved in the care of patients before, during and after the surgery, along with surveying the patients themselves. Standardized protocols have been developed to enhance recovery after surgery in a way that emphasizes safety and value to the patient. For example, benchmarks have been set for when and how to begin mobilizing postoperative patients, including specific criteria they need to pass to advance to the next level. This has led to a substantial increase in the percentage of patients who are able to ambulate under their own power — an important achievement that stimulates the patient’s motivation to recover — the first morning after elective surgery, from 20 percent to 60 percent. Promptly getting a patient up and moving dramatically reduces the risk of dangerous postsurgical complications, such as pneumonia and deep-vein thrombosis, and increases the likelihood of a shorter hospital stay.

  Dr. Michael Yeh  
  Standardization of care “isn’t one-size-fits all. The goal of standardization is to make sure the right patient is getting the right care in the right place at the right time for the right cost,” says Dr. Michael Yeh.

“Standardization allows us to be sure we are meeting specific goals for the care items most important to our patient population,” says Nancy McLaughlin, MD (FEL ’12), assistant clinical professor of neurosurgery and leader of the department’s care-redesign effort, which also has focused on pain management, patient education and communication and transition of care among care providers. “Standardization drives care delivery so that we are not reinventing the process every time a care provider comes into contact with a patient.”

She notes that the standardization of processes shouldn’t be undertaken blindly; rather, it should be done in conjunction with a value-redesign initiative that will ensure improved outcomes and reduced costs, with room for customization of elements, where appropriate.

“Ninety percent of the patient problems we see can be managed with some type of algorithm,” says Michael Yeh, MD, section chief of the UCLA Endocrine Surgery Program. “And I would argue that you could bring it to 99 percent by making a thinking algorithm that adapts.”

Dr. Yeh’s group has developed and studied two clinical pathways for endocrine-surgery patients. One assigns patients to the most-appropriate surgical setting based on the clinical complexity of their case. It has resulted in substantially lower costs by shifting appropriate patients to community inpatient or ambulatory-care facilities. A second standardizes the initial management of patients with thyroid cancer by assigning them to care pathways based on their parathyroid-hormone levels. The new protocol resulted in a 70-percent reduction of laboratory tests, while decreasing the likelihood of patients presenting with critically low calcium levels by 30 percent.

“We have reduced costs and improved quality by eliminating wasteful services,” Dr. Yeh says. He argues that improved quality will often go hand-in-hand with reduced cost because “the most-expensive thing you can have in surgery is a complication that requires additional care.”

In cardiac surgery, the complexity of the cases and the multidisciplinary-team approach to care demand that it be highly protocol-driven — from the preoperative evaluation of patients to the surgery itself and through the postoperative treatment and post-discharge care. But there are inevitably variations in the care that is provided, and those become an opportunity to formally discuss and improve on the standards, says Richard Shemin, MD, chief of cardiothoracic surgery at UCLA.

Dr. Shemin heads a consortium of the five University of California chiefs of cardiac surgery that is examining aspects of the operations that lead to costly complications. The group is seeking to develop best-practices by sharing clinical and financial data across the UC sites. One of the projects has focused on reducing atrial fibrillation, a postoperative arrhythmia that can cause stroke, keep patients in the hospital longer and require expensive and invasive care. The group has found that assigning patients to low-, intermediate- and high-risk categories based on risk factors and then treating high-risk patients more aggressively with prophylactic therapy reduces the incidence of atrial fibrillation more efficiently. Other areas being addressed by the consortium include blood conservation, swallowing difficulties after heart-surgery intubations and protocols for discharge and follow-up to prevent hospital readmissions.
“The established norms for treatment represent the status quo,” Dr. Shemin notes. “By querying our robust database to look for trends and assess what happens when patients are treated outside the established norms, we can find ways to improve on practice guidelines.”

THE CONCEPT OF STANDARDIZING CARE-PATHWAY protocols to reduce unsupported variations and improve quality isn’t new. Nor is UCLA’s leadership in the effort. A similar movement took hold in the 1990s, with the UCLA kidney-transplant program serving as a national benchmark for its ability to produce the best results with the greatest efficiency through standardized practices. UCLA’s place at the forefront of the movement has remained constant. This was illustrated most recently when UCLA Health was selected by the Centers for Medicare and Medicaid Services (CMS) as the only academic medical center in California to sponsor and participate in the federal government’s Medicare Shared Savings Program as an accountable care organization — working with the CMS to enhance care coordination as a way to provide high-quality service and care to Medicare fee-for-service beneficiaries while reining in costs.
What’s changed in the last decade, both nationally and at UCLA, has been the enhanced focus on efficiency in the face of growing concerns about healthcare spending. “We have not been on a sustainable path,” says Dr. Skootsky. “Society is telling the healthcare industry that we have to figure out ways of doing this better and less expensively. With a standardized, evidence-based approach to care, we can have a higher level of confidence that we aren’t utilizing unnecessary resources.”

Wide variations in cost for the same procedures across institutions, and even within the same institution, provide strong evidence that new efficiencies can be achieved. “You can study 20 different surgeons and find that the costs of delivering a joint-replacement operation vary dramatically, even when the unit prices and patient-acuity levels are the same,” Dr. Rosenthal notes. “That tells us that if we were able to reduce that variance, we would have a more-efficient health system, with more resources available for other things.”

At the individual patient level, Dr. Yeh argues, the issue is value, not cost. “People aren’t looking for the cheapest care possible, because that would be no care at all,” he says. “We need to be able to provide the highest-quality care for the lowest-possible cost.”

Dr. Yeh found in his study that moving simple operations out of the hospital to the outpatient-surgery center cut costs in half. “Those patients are getting the same quality, if not higher quality, because we can streamline the operation so that many of them go home the same day,” he says. “By holding the quality constant and dropping the cost by half, we double the value.”

Standardization also makes it easier for health systems to measure their performance. “If 100 people have a gall-bladder operation, and each time you improvise — using slightly different medications, different lab tests, different vital signs — you don’t have a controlled experiment that you can look back at in a year,” Dr. Yeh says. “That makes systematic improvement impossible.” Beyond affording accountability, standardization promotes advances in care through testing the effects of incremental changes against a backdrop in which all other aspects of care remain constant. “Standardization doesn’t mean care pathways are static,” Dr. Yeh says. “They evolve through a process of continuous improvement.”

The potential for standardization to improve the quality and efficiency of care at UCLA is bolstered by the health system’s electronic health-record (EHR) program. Instituted in 2013, the EHR enables the records of UCLA Health patients to be immediately accessible, regardless of where the patients are seen, and facilitates standardization across the enterprise in the way medical information is stored and accessed. Beyond that, UCLA’s EHR provides clinical-decision support to make it easier for providers to follow evidence-based approaches. More than 1,000 standardized order sets, designed by UCLA clinicians, are used in both the hospital and ambulatory settings.

“As you see patients with specific medical problems, you can call up one of these evidence-based order sets, and it will guide you through the care of the patient,” explains Michael Pfeffer, MD (RES ’07), assistant clinical professor of medicine and chief medical informatics officer, who was the lead physician in implementing UCLA Health’s EHR. Active clinical-decision support is also provided in the form of alerts. Providers are notified of everything from potentially dangerous drug-drug and drug-allergy interactions to notifications specific to the patient’s disease state or health-maintenance needs, such as reminders of when an influenza vaccine or cancer screening is due.

The EHR also makes it possible to conduct the types of systematic analyses that can inform quality-related efforts. “We’re able to look at gaps in processes based on evidence,” Dr. Pfeffer explains. “It helps us identify opportunities for improvement across our enterprise in a much-faster, more data-driven way.”

IDEALLY, STANDARDIZATION OF CARE PROMOTES ADHERENCE to evidence-based medicine, making decisions about patient care supported by the best-available research findings. But there are many aspects of patient care that have been studied inadequately, if they’ve been studied at all. “It’s easy to say that we’re going to only practice evidence-based medicine,” Dr. Skootsky says. “The problem is that there isn’t strong evidence for every situation.”
In such cases, clinical teams will often get together in an effort to agree on what is the best practice so that decisions don’t come down to individual preferences. Another approach, increasingly applied at UCLA and other major institutions, involves bringing clinicians together, agreeing on a protocol, applying it systematically, tracking the data and then learning from the results. Where applicable, input is collected from patients about what’s important to them before deciding on the new protocol. “Standardization is very consistent with an agenda that pushes for more shared decision making and getting patients involved in the design of care delivery,” Dr. Skootsky notes.

  Dr. Samuel A. Skootsky  
  Standardization makes for a more consistent product, and that “almost by definition, means higher quality,” says Dr. Samuel A. Skootsky.

To enhance the value of the care it provides for common conditions, the UCLA Department of Urology has conducted research on patients’ preferences and their experiences with treatment at UCLA. The initiative began with a focus on benign prostatic hyperplasia (BPH), a noncancerous enlargement of the prostate that is common as men get older and can lead to bothersome urinary symptoms. “We were offering at least five surgical therapies for that indication, and patients were often confused about what to do, which was a source of dissatisfaction for many of them,” says Christopher Saigal, MD ’94 (RES ’00, FEL ’01), MPH, vice chair of the department, who has headed the effort. The survey of patients revealed some surprising findings that led to changes, Dr. Saigal says. For one, patients were more concerned than the UCLA urologists realized about having to use catheters at home after surgery. To address that concern, the department created a video on catheter management that became the most-widely visited page on its website, drawing thousands of views each month. The department also instituted shared-decision-making processes to assist patients in coming to treatment choices consistent with their preferences and the evidence, and it produced a video for referring physicians on how to optimally manage patients with BPH prior to referral for potential surgery.

Finally, drawing from the EHR database, dashboards have been created for individual physicians comparing their outcomes across BPH therapies. Measures include infection rates, emergency-room visits, hospital-readmission rates and the rate of patients returning to medical therapy, as well as each physician’s costs for delivering each service. This enables the physicians to make value-based recommendations to their patients, Dr. Saigal notes. Similar efforts are underway for prostate and bladder-cancer treatments.

“Standardized protocols, enabled by the immense amount of observational data we’re getting through electronic health records, can make a big impact on improving care,” Dr. Saigal says. “But they have to be informed by patient input and designed with patients’ goals in mind. Patients have different preferences, and the pathways must incorporate those.”

Daniel Hommes, MD, PhD, director of the UCLA Center for Inflammatory Bowel Diseases and quality director of UCLA’s Division of Digestive Diseases, says that the value-based care pathways his group has instituted are “creating structure out of organized chaos.”

For a variety of chronic diseases — starting with inflammatory bowel disease and then moving on to conditions that include other gastrointestinal disorders, as well as diabetes, chronic back pain and rheumatoid arthritis — Dr. Hommes’ team has employed national and international practice guidelines as frameworks for standardized-care pathways. Using these as starting points, providers learn on a patient-by-patient basis which elements are most effective and where more emphasis needs to be placed. Then they adjust their patient’s care plan each year through a feedback loop informed by a “value quotient” — a measure that incorporates the annual burden of the patient’s disease, patient-defined quality of life and work productivity, divided by the cost of the care.

“When patients are running around from doctor to doctor getting all kinds of tests, that’s organized chaos,” Dr. Hommes says. “We start from the literature. Then we fine-tune the patient’s care each year based on the value quotient. We need those standardized-care pathways to capture meaningful data that will enable us to move toward personalized-care pathways.”

The idea that standardization can be used to enhance care based on patient preferences and experiences isn’t surprising to Dr. Yeh. “This isn’t one-size-fits all. The goal of standardization is to make sure the right patient is getting the right care in the right place at the right time, for the right cost,” he says. “People complain that standardization promotes ‘cookbook medicine.’ What’s wrong with having a cookbook? Try to find one household that doesn’t have one.”

Dan Gordon is a regular contributor to U Magazine.

 





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