Variations in Care, Part 1: Reducing Variation is Key to Achieving the Quadruple Aim

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As the cardiovascular industry continues to evolve and clinician's time is stretched thin, we are all looking for solutions to improve efficiency and outcomes. Reducing variations in care across an organization can go a long way towards achieving the Quadruple Aim of better outcomes at a lower cost and improved clinician and patient experiences, something we are all striving for.

In this article, we delve into why cardiovascular organizations need to evolve their clinical strategies and limit operational variation, and how health care can learn from the manufacturing industry and supply chain principles.

Developing a Proactive Clinical Strategy Used to Limit Unnecessary Variation

Cardiovascular care delivery is becoming complex with expanded offerings in all areas – procedures, pharmaceutical therapies and delivery model demands. In addition, population health has emerged, and quality and cost have taken a priority over volumes. Cardiology care includes chronic disease management and episodic care related to procedure performance and management.

There is also a significant shift to care in the ambulatory setting with the emergence of outpatient procedures, cost containment and changes to reimbursement models. Cardiology is one of a few specialty areas in medicine that requires systems in place for nearly all care settings. Systems that are reliable and scalable need strategy and alignment.

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In other words, unnecessary variation needs to be removed from the equation.

High-performing cardiovascular programs need to start with a defined clinical strategy. This strategy can best be summed up as a set of specific criteria addressing: who are the patients that need treatment; what should be done for this population; what is the most effective delivery model; where should it be done (and where should it not be done); and who should perform the care.

All of this is designed to deliver care in the most highly reliable fashion and at the highest value.

Atrial fibrillation (AFib) care, for instance, has multiple objectives that need to be met including rate control, rhythm management, stroke prevention and risk factor management. Evidence-based guidelines exist that outline what should be done, yet studies suggest up to one third of patients are not treated according to these guidelines.

In addition, with all these objectives, it is very difficult for an individual provider to get it right each and every time. Developing the clinical strategy for AFib management – including definitions, objectives of care and delivery model – will allow for a more consistent method to care for this population and increase adherence, which then results in more consistent outcomes (i.e., value).

This same concept can be applied to any of the cardiovascular patient populations.

The more programs can define clinical structure to assure evidence-based guideline adherence and, when evidence does not exist, create consensus-based standards, the better the outcomes for its patient populations. This is true whether it is heart failure management, structural heart procedure delivery, secondary coronary artery disease prevention and beyond.

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This concept is not new to cardiology. We have become very good as a profession in managing ST-segment elevation myocardial infarction (STEMI) patients within a certain timeline, with a defined procedure and the right delivery team.

Cardiovascular STEMI care includes some great examples of how a defined outcome pushed organizations to bring together the appropriate stakeholders to define the care pathways and processes needed to meet the outcome. There is typically very little variation in how STEMI patients are managed in an individual institution.

Systematic leadership and governance structure are needed to not only define the clinical strategy but also to oversee the disease management programs. The clinical strategy will assist with defining the care pathways, processes and protocols needed for teams to deliver the care competently and reliably.

In an environment where most of our programs are seeing thousands of patients a day with simple to complex issues, a lack of strategy and standardization will lead to less than desired outcomes.

Stay tuned for part 2 and part 3 in the coming weeks.

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This article is authored by Ginger Biesbrock, PA-C, MPH, MPAS, AACC, senior vice president of Consulting at MedAxiom, and Talal T. Attar, MD, MBA, FACC, director of the Heart and Vascular Center and Cardiac Catheterization Laboratories, University Hospital East.