Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality.
Transformation of US health care from volume to value requires meaningful quantification of costs and outcomes at the level of individual patients.



To measure the association of a value-driven outcomes tool that allocates costs of care and quality measures to individual patient encounters with cost reduction and health outcome optimization.



Uncontrolled, pre-post, longitudinal, observational study measuring quality and outcomes relative to cost from 2012 to 2016 at University of Utah Health Care. Clinical improvement projects included total hip and knee joint replacement, hospitalist laboratory utilization, and management of sepsis.



Physicians were given access to a tool with information about outcomes, costs (not charges), and variation and partnered with process improvement experts.



Total and component inpatient and outpatient direct costs across departments; cost variability for Medicare severity diagnosis related groups measured as coefficient of variation (CV); and care costs and composite quality indexes.



From July 1, 2014, to June 30, 2015, there were 1.7 million total patient visits, including 34 000 inpatient discharges. Professional costs accounted for 24.3% of total costs for inpatient episodes ($114.4 million of $470.4 million) and 41.9% of total costs for outpatient visits ($231.7 million of $553.1 million). For Medicare severity diagnosis related groups with the highest total direct costs, cost variability was highest for postoperative infection (CV = 1.71) and sepsis (CV = 1.37) and among the lowest for organ transplantation (CV ≤ 0.43). For total joint replacement, a composite quality index was 54% at baseline (n = 233 encounters) and 80% 1 year into the implementation (n = 188 encounters) (absolute change, 26%; 95% CI, 18%-35%; P < .001). Compared with the baseline year, mean direct costs were 7% lower in the implementation year (95% CI, 3%-11%; P < .001) and 11% lower in the postimplementation year (95% CI, 7%-14%; P < .001). The hospitalist laboratory testing mean cost per day was $138 (median [IQR], $113 [$79-160]; n = 2034 encounters) at baseline and $123 (median [IQR], $99 [$66-147]; n = 4276 encounters) in the evaluation period (mean difference, -$15; 95% CI, -$19 to -$11; P < .001), with no significant change in mean length of stay. For a pilot sepsis intervention, the mean time to anti-infective administration following fulfillment of systemic inflammatory response syndrome criteria in patients with infection was 7.8 hours (median [IQR], 3.4 [0.8-7.8] hours; n = 29 encounters) at baseline and 3.6 hours (median [IQR], 2.2 [1.0-4.5] hours; n = 76 encounters) in the evaluation period (mean difference, -4.1 hours; 95% CI, -9.9 to -1.0 hours; P = .02).



Implementation of a multifaceted value-driven outcomes tool to identify high variability in costs and outcomes in a large single health care system was associated with reduced costs and improved quality for 3 selected clinical projects. There may be benefit for individual physicians to understand actual care costs (not charges) and outcomes achieved for individual patients with defined clinical conditions.
University of Utah, Salt Lake City.
Vivian S
VS
Lee
University of Utah, Salt Lake City.
Kensaku
K
Kawamoto
University of Utah, Salt Lake City.
Rachel
R
Hess
University of Utah, Salt Lake City.
Charlton
C
Park
University of Utah, Salt Lake City.
Jeffrey
J
Young
University of Utah, Salt Lake City.
Cheri
C
Hunter
University of Utah, Salt Lake City.
Steven
S
Johnson
University of Utah, Salt Lake City.
Sandi
S
Gulbransen
University of Utah, Salt Lake City.
Christopher E
CE
Pelt
University of Utah, Salt Lake City.
Devin J
DJ
Horton
University of Utah, Salt Lake City.
Kencee K
KK
Graves
University of Utah, Salt Lake City.
Tom H
TH
Greene
University of Utah, Salt Lake City.
Yoshimi
Y
Anzai
University of Utah, Salt Lake City.
Robert C
RC
Pendleton
D022126:Access to Information; D019643:Arthroplasty, Replacement / Q000191:economics* / Q000592:standards*; D003363:Cost Control; D003661:Decision Support Techniques; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay; D008137:Longitudinal Studies; D008297:Male; D006278:Medicare; D017063:Outcome Assessment, Health Care; D010820:Physicians; D058996:Quality Improvement; D018805:Sepsis / Q000191:economics* / Q000628:therapy; D012720:Severity of Illness Index; D013530:Surgical Wound Infection; D014481:United States