Your Path to Program Success: Expert Advice

Transforming Quality, Outcomes, and Cost Savings With Patient-Centered Care in the Cath Lab

Gary Clifton, Vice President, Care Pathway Solutions, talks with Amit P. Amin, MD, MSc, MBA, Associate Professor of Medicine, Dartmouth Geisel School of Medicine; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

Gary Clifton, Vice President, Care Pathway Solutions, talks with Amit P. Amin, MD, MSc, MBA, Associate Professor of Medicine, Dartmouth Geisel School of Medicine; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

In our last article,1 we discussed the acquisition of ePRISM by Terumo and what the future might hold for combining the capabilities of a clinical decision support software platform with our experienced consultative solutions group. We are now a couple of months’ post acquisition and we are excited to announce that Terumo Business Edge will henceforth be known as Terumo Health Outcomes. We feel our offering of ePRISM is going to go a long way in bringing tremendous value to health systems in the delivery of better quality outcomes that are not only providing improved cost efficiencies, but are integrated into the clinical workflow, thus generating improved operational efficiencies.

In this month’s article, we thought we would take a step back and bring you greater insight into the extensive capabilities and advantages that can be gained by having ePRISM as a part of your cath lab program. To that end, we have asked Dr. Amit Amin, formerly of Barnes-Jewish Hospital and now at Dartmouth Hitchcock Medical Center, to join us. Dr. Amin, during his tenure at Barnes-Jewish, had extensive experience with patient-centered approaches in the cath lab, and has published on the financial and economic benefits patient-centered care in these settings. We ask him to delve into his experience and key in on some of the advantages that his publications may not have emphasized.

Thank you for joining us, Dr. Amin. Can you describe ePRISM and provide us with a historical perspective of your involvement with this technology?

ePRISM is a health information technology platform that facilitates the translation of risk prediction models to the point of care in the cath lab for patients undergoing cardiac catheterization. Specifically, it allows the translation of risks of bleeding, acute kidney injury, mortality, etc., before the patient undergoes cardiac catheterization. At Barnes-Jewish Hospital, we first started using ePRISM in 2013, when we received a K grant award from the National Institutes of Health, through which we pioneered its use for prevention of acute kidney injury using a patient-centered approach.At that time, I had just finished my fellowship and strongly believed (and still do!) that patient-centered care has the ability to transform clinical decision making to improve patient outcomes. This is especially true for patients undergoing cardiac catheterization in the cardiac cath lab. Most of our patients have numerous cardiovascular conditions and medical comorbidities that make them vulnerable to complications such as bleeding, acute kidney injury, stroke, and ultimately, death. From a hospital perspective, many patients are at high risk for readmissions and taking care of these sick patients is quite costly. For such complex patients, a formal approach to risk stratification instantaneously facilitates patient-centered care, with the result that not only do patient outcomes improve, but there is a reduction in hospital costs.

From a clinical perspective, can you tell us what benefits you derived, how it was integrated into your clinical workflow, and how it impacted your quality outcomes?

Health information technology innovations in health care, if developed and used properly, hold tremendous value and promise, and have the potential to greatly enhance the patient-centered aspect of care, especially in facilitating the “meaningful use” provisions of the electronic health record. ePRISM is specifically designed to help clinicians better know their patients, and use this knowledge to inform and improve care at the bedside in the cath lab.

Our K grant was funded and ePRISM was successfully implemented in the cardiac cath lab at Barnes-Jewish Hospital in early 2013. We developed the methods for contrast calculations, and also developed decision aids for physicians and nurses that allowed them to understand patient-specific risks before the patient went on the cath table. Finally, we developed feedback reports that facilitated physician engagement. ePRISM was effortlessly integrated into our clinical workflow with help from our health IT folks. We held a couple of formal training sessions to familiarize the cath lab staff and physicians with this new workflow. All of the above activities required about 3 months. Following the successful implementation, within a short span of 6 to 12 months, we noted rapid improvements in acute kidney injury and a reduction in our contrast volume use of nearly 40%.2 Additionally, there were other downstream effects, such as reduction in bleeding, an improvement in mortality, and a reduction in 30-day readmissions.2 From a hospital perspective, the cost of percutaneous coronary intervention (PCI) reduced by 30%,2 representing substantial savings to the hospital. We started a patient-specific, risk-based, same-day discharge program for elective PCI that led to improvements in patient satisfaction as well. I believe technologies such as ePRISM greatly facilitate patient-centered care at the bedside, which allows for rapid improvements in care and reductions in cost.

You published on a single-center experience while at Barnes-Jewish Hospital as it related to the economics of same-day discharge and use of transradial access,3 both of which are measures that ePRISM incorporates into its risk calculations. Can you expand upon just how ePRISM played a part in your results?

ePRISM was the catalyst that facilitated a patient-centered approach for same-day discharge at Barnes-Jewish Hospital. Patient-centered care is the provision of care that is individualized and responsive to individual patient characteristics and needs. Patients undergoing PCI have a varying risk profile. ePRISM allowed us to be responsive to individual patient risk profiles and their specific needs. We developed and implemented a decision aid using a patient-centered care framework to facilitate same-day discharge (SDD) after PCI.3 The patient-centered SDD program at Barnes-Jewish Hospital required prospectively identifying risks of bleeding, mortality, and acute kidney injury, with a patient-specific determination of a safe contrast limit at the point of care before PCI. We used the American College of Cardiology’s National Cardiovascular Data Registry (NCDR) CathPCI Registry models to identify the risks of bleeding, mortality, and acute kidney injury, and developed a method for estimating the safe contrast limits. These were implemented using clinical decision aids that provided each patient’s individual risks before the procedure. Risks were prospectively reviewed by the interventional cardiologist performing the procedure in the catheterization laboratory holding area to define the appropriate risk mitigation strategies, including both bleeding avoidance strategies and contrast limits. After the procedure, the interventionalist and a catheterization laboratory holding area nurse ascertained procedural success, if the risks were successfully mitigated, and if the patient was stable after the procedure. The findings were reviewed with the patient and family members, and, if everyone agreed, the patient was discharged the same day, even if the patient had undergone a complex PCI or had numerous comorbidities. Thus, our protocol maximized patient centeredness at the point of care, and we structured the intervention so that it was reproducible and scalable.

What did ePRISM allow you to achieve financially when working with payers?

ePRISM allowed us to implement the patient-centered approach successfully. When patient-centered care was successfully implemented at Barnes-Jewish Hospital, it resulted in better upfront recognition of risk, prevention of complications (which are quite costly!), and led to reduction in hospital costs. Because complication rates reduced substantially, it allowed better contract negotiations with private payers and greater reimbursement from governmental payers via their various programs such as readmission prevention, patient safety, and complication prevention programs.

What is the utility of the risk avoidance recommendations ePRISM provides, and the accuracy and reliability of those data?

These risk prediction models (as described above) are derived from millions of patients in the American College of Cardiology’s NCDR CathPCI registry. Hence, these estimates are reliable and are generalizable to the patients undergoing PCI. The risk avoidance strategies and recommendations are also based on strong evidence that has been derived from randomized trials and validated in large patient populations such as the CathPCI registry. In an interesting publication, we noted that physicians who participated more in patient-centered decision making seemed to have better outcomes than physicians who did not follow these recommendations. Whether this effect is causal or more of an association remains to be seen.

What do you see as the future of calculating prospective risk algorithms and what insights do you believe that future will allow us to unlock?

The future is bright for health information technology innovation solutions such as ePRISM. In this digital age, machine learning and artificial intelligence approaches are showing great promise in advanced modeling and risk prediction, with a greater degree of accuracy. If we are able to translate these approaches to the bedside, we will have greater certainty in prediction of adverse complications, which could be very powerful and quite frankly, transformational, for patient-centered care at the bedside.

What challenges did you see related to the adoption and use of ePRISM?

Any new change is always limited by some barriers. However, these barriers can be overcome. At Barnes-Jewish Hospital, we noted variation in the adoption and use of ePRISM. It was not fully embraced by all physicians uniformly. What is really interesting is that there was a strong correlation between the degree of adoption and improved patient outcomes. Those who understood and practiced these recommendations achieved a higher degree of patient-centered care, which in turn was strongly correlated with improved patient outcomes. In learning from these experiences, we see that adoption of any new technology requires a buy-in from physicians, hospital administration, and nursing staff in the cath lab.

For labs that might be considering engaging with Terumo Health Outcomes, what advantages should physicians and staff expect when using the ePRISM technology?

With successful implementation of this technology, one might expect to see a large and rapid improvement in outcomes, as well as a reduction in costs. Successful implementation may also lead to a reduction in readmissions and an improvement in patient satisfaction. At Barnes-Jewish Hospital, ePRISM certainly led to improvements for patients, physicians, and the hospital — a win, win, win for all! 

References
  1. Clifton G, Graver R. Terumo Business Edge expands capabilities and solutions. Cath Lab Digest. 2021 Mar; 29(3). Accessed May 4, 2021. Available online at https://www.cathlabdigest.com/terumo-business-edge-ePRISM
  2. Amin AP, Crimmins-Reda P, Miller S, et al. Reducing acute kidney injury and costs of percutaneous coronary intervention by patient-centered, evidence-based contrast use. Circ Cardiovasc Qual Outcomes. 2019 Mar; 12(3): e004961. doi: 10.1161/CIRCOUTCOMES.118.004961
  3. Lindner SM, McNeely CA, Amin AP. The value of transradial: impact on patient satisfaction and health care economics. Interv Cardiol Clin. 2020 Jan; 9(1): 107-115. doi: 10.1016/j.iccl.2019.08.004
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