Using Incentives to Improve Resource Utilization: A Quasi-Experimental Evaluation of an ICU Quality Improvement Program.
OBJECTIVE
Healthcare systems strive to provide quality care at lower cost. Arterial blood gas testing, chest radiographs, and RBC transfusions provide an important example of opportunities to reduce excess resource utilization within the ICU. We describe the effect of a multifaceted quality improvement program designed to decrease the avoidable arterial blood gases, chest radiographs, and RBC utilization on utilization of these resources and patient outcomes.


METHODS
Prospective pre-post cohort study.


METHODS
Seven ICUs in an academic healthcare system.


METHODS
All adult ICU patients admitted to study ICUs during consecutive baseline (n = 7,357), intervention (n = 7,553), and follow-up (n = 7,657) years between September 2010 and August 2013.


METHODS
A multifaceted quality improvement program including provider education, audit and feedback, and unit-based provider financial incentives targeting arterial blood gas, chest radiograph, and RBC utilization.


RESULTS
The primary outcome was the number of orders for arterial blood gases, chest radiographs, and RBCs per patient. Compared with the baseline period, unadjusted arterial blood gas, chest radiograph, and RBC utilization in the intervention period was reduced by 42%, 26%, and 17%, respectively (p < 0.01). After adjusting for potentially relevant patient factors, the intervention was associated with 128 fewer arterial blood gases, 73 fewer chest radiographs, and 16 fewer RBCs per 100 patients (p < 0.01). This effect was durable during the follow-up year. This reduction yielded an approximate net savings of $1.5 M in direct costs over the intervention and follow-up years after accounting for the direct costs of the program. Unadjusted hospital mortality decreased from 7% in the baseline period to 5.2% in the intervention period (p < 0.01). This reduction remained significant after adjusting for patient factors (odds ratio = 0.43; p < 0.01).


CONCLUSIONS
Implementation of a multifaceted quality improvement program including financial incentives was associated with significant improvements in resource utilization. Our findings provide evidence supporting the safety, effectiveness, and sustainability of incentive-based quality improvement interventions.
1Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Emory University, Atlanta, GA.2Emory Critical Care Center, Emory University, Atlanta, GA.3Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, GA.4Department of Surgery, Emory University, Atlanta, GA.
David J
DJ
Murphy
Peter F
PF
Lyu
Sara R
SR
Gregg
Greg S
GS
Martin
Jason M
JM
Hockenberry
Craig M
CM
Coopersmith
Michael
M
Sterling
Timothy G
TG
Buchman
Jonathan
J
Sevransky
D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data*; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D008297:Male; D008875:Middle Aged; D010816:Physician Incentive Plans; D015397:Program Evaluation; D011446:Prospective Studies; D058996:Quality Improvement