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Evaluation of two interventions to reduce the ancillary costs of outpatient care for rheumatoid arthritis.

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ARTHRITIS & RHEUMATISM
Vol. 39, No. 1, January 1996, pp 177-178
0 1996, American College of Rheumatology
177
CONCISE COMMUNICATION
-
Evaluation of two interventions to reduce the ancillary
costs of outpatient care for rheumatoid arthritis
Managed care and capitation require rheumatologists
to reduce costs while maintaining quality. Ancillary tests
account for over half of the outpatient charges for treatment
of rheumatoid arthritis (RA) in our center. We report the
results of 2 interventions designed to reduce the costs of
ancillary tests.
Setting. Our faculty practice has over 5,000 return
patient visits annually for treatment of RA. Charges for all
ancillary tests are recorded on a computerized hospital
accounting system.
Interventions. 1) The hospital chemistry laboratory
agreed to develop a chemistry profile five, which consists of
tests for alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, albumin, and creatinine. The
profile five can be used for any patient, but is especially
appropriate for monitoring toxicity in patients receiving
methotrexate and nonsteroidal antiinflammatory drugs. The
charge for the profile five is $21.00,as compared with $45.00
for the profile twenty, which also includes electrolytes,
glucose, blood urea nitrogen, and other tests.
2) We sent quarterly reports to each physician documenting his or her mean ancillary charges per patient per
visit for specific diagnoses, along with mean charges of the
entire practice for comparison. There was no explicit discussion regarding the appropriate level of test ordering, and
physicians were not provided data on charges of other
individual physicians.
Analysis of intervention effect. Both interventions
were introduced in the third quarter of fiscal year 1993. We
compared mean charges per visit during the preintervention
period, defined as all of fiscal year 1992 and the first quarter
of 1993,with mean charges per visit during the postintervention period, defined as the last 3 quarters of fiscal year 1994
and the first quarter of 1995.The 4 quarters surrounding the
interventions were examined descriptively (Figure l), but
were omitted from the analyses of intervention effects, to
allow a period of physician adaptation to the intervention.
For this report, we analyzed data on all return patient
visits for treatment of RA, irrespective of whether patients
were taking medications that require frequent monitoring.
Diagnoses were specified by physicians on encounter forms.
Physicians with <60 return visits during the pre- or postintervention periods were excluded, which left 15 rheumatologists in the analysis. The preintervention period included
5,176 patient visits, and the postintervention period had
4,784 patient visits.
We analyzed the 3 largest charge categories: chemistry, hematology, and diagnostic radiology. In addition, we
analyzed total ancillary charges, which included microbiology, cytology, pharmacy (e.g., use of injectable corticosteroids), electrocardiography, immunology, and pulmonary
function tests, along with other items. We obtained quarterly
reports of mean charges per visit for each physician from the
hospital computing system. We weighted these by the number of visits to each physician in the quarter and calculated
chemistry
_ _ _ * - - -total minus chemistry
02.4
a1.a
m1.a
e1.4
01.1
o a . 1 m1.a ma.4 e 4 . q 8 4 . 1 ( 4 - 1
04.4
(6-1
Quarter
Figure 1. Changes in outpatient charges for chemistry tests compared with total ancillary charges without chemistry, by quarter
during the study interval. Charges are plotted as the percentage of
change from the mean preintervention charge. The intervention was
introduced in the third quarter of 1993.
a mean charge per visit for the preintervention and postintervention periods. The differences between the pre- and
postintervention
charges for. the. entire
group of physicians,
. ..
. . . .. . _
.
and tor each individual physician, were compared with
paired t-tests.
During the study period, charges per laboratory test
generally increased in the range of 0-5% annually. Analyses
adjusted for a 5% inflation rate revealed somewhat lower
charges in later years than unadjusted analyses, but the same
relative difference was observed in the effects of the 2
interventions; therefore, only the unadjusted results are
presented.
Results. Total ancillary charges decreased by $10.10,
or 11% per visit (Table 1) between the pre- and postintervention periods (P = 0.18). Over 80% of this reduction was
due to a decrease in chemistry charges of $8.20,or 32% per
visit (P = 0.0005).Hematology charges decreased by 6% per
visit, and radiology charges actually increased.
Ten of the 15 physicians reduced total ancillary
charges following the interventions, and 13 physicians reduced chemistry charges. Variability in charges among physicians, reflected by the standard deviation (see Table l),
decreased for chemistry charges, and increased for hematology and radiology.
Chemistry charges remained relatively constant until
the intervention, when they dropped dramatically to 20-30%
below the preintervention mean (Figure 1). Nonchemistry
~
178
CONCISE COMMUNICATION
Table 1. Mean charges per office visit for ancillary tests*
Preintervention
Postintervention
Difference
Charges
Mean,$
SD
Range
Mean, $
SD
Range
Mean, $
SD
Range
Total ancillary
Hematology
Chemistry
Radiology
Other
Total ancillary
without chemistry
90.9
26.6
25.8
12.6
25.9
65.0
28.0
5.8
7.1
5.2
15.4
22.4
(55.3-168)
(20.9-38.0)
(15.041.7)
(4.6-21.9)
(3.5-68.9)
(36.7-128)
80.7
25.0
17.7
14.3
23.8
63. I
21.4
6.7
5.2
7.4
11.8
17.6
(49.4-125)
(13.4-38.3)
(11.0-30.2)
(5.9-36.3)
(2.642.6)
(36.0-%.2)
10.1
1.6
8.2t
-1.7
2.0
1.9
27.6
6.1
7.1
2.4
15.1
22.4
(-31.1-88.4)
(-8.0-11.6)
(-1.7-23.5)
(-27.9-9.1)
(-48.616.1)
(-64.9-35.1)
* SD = standard deviation.
t P = O.OOO5 for difference in mean chemistry charges; P > 0.15 for all other differences.
charges remained within 15% of the preintervention mean
throughout the study period.
Discussion. Use of the profile five was associated
with a reduction in chemistry charges of $8.00 per visit
(32%). This reduction was immediate and sustained (Figure
1). With over 5,200 return patient visits for treatment of RA
annually, we estimate that use of the profile five reduced our
charges for RA by more than $30,000, with additional
savings realized among patients with other diagnoses. This
intervention was administrative and required little change in
physician behavior.
Feedback of provider-specific charges was less effective. Excluding savings in chemistry, other ancillary charges
decreased $2.00 per visit (3%) in unadjusted analyses. While
variability in total ancillary and chemistry charges decreased, variability in hematology and radiology charges
increased.
Test ordering accounts for substantial health care
costs and is frequently excessive (1). A variety of interventions have been used to reduce test ordering, including
administrative procedures, feedback to physicians, education regarding appropriateness, and financial incentives (reviewed in reference 2). combinations of these strategies
appear to be most effective (2). While feedback to physicians
has reduced test utilization in the short term (3), physicians
generally already know whether they are high or low test
orderers (4), which limits the success of feedback unless it is
linked to discussions about appropriate utilization (5,6).
Several limitations must be acknowledged. Our analyses do not control for recent secular trends toward more
efficient use of the laboratory. However, the dramatic reduction in chemistry charges immediately following the interventions (Figure 1) suggests a true effect rather than a
secular trend. Also, charges may be considerably higher
than costs (7), which were not available for analysis. However, incorporating true costs into the analysis would not
change the relative effects of the 2 interventions. Further, we
have neither data on the number of tests ordered nor the
frequency of use of each chemistry profile; therefore, we
cannot distinguish between reduction in number of tests
ordered and lower charge per test. In addition, we do not
know precisely how the minor increases in charges for
specific tests influenced the average charges per patient.
Finally, the feedback intervention did not distinguish patients on the basis of their medications (e.g., methotrexate);
such stratification might have made the intervention more
compelling to physicians.
With capitated reimbursement likely to play a larger
role in the organization of rheumatology practice, attention
will focus increasingly on ancillary test ordering. We encourage additional evaluation of strategies to reduce costs while
maintaining quality of care.
Supported by NIH grant AR-36308. Dr. Katz’s work was supported
in part by an Arthritis Investigator Award from the Arthritis Foundation.
Jeffrey N. Katz, MD, MS
Elizabeth A. Wright, PhD
Kan D. Lynch, AB
Michael E. Weinblatt, MD
Brigham and Women’s Hospital
Boston, M A
1 . Griner PF, Glaser RJ:Misuse of laboratory tests and diagnostic
procedures. N Engl J Med 307:133&1339, 1982
2. Eisenberg JM, Williams SV: Cost containment and changing
physicians’ practice behavior: can the fox learn to guard the
chicken coop? JAMA 246:2195-2201. 1981
3. Schroeder AS, Kenders K, Cooper JK, Piemme TE: Use of
laboratory tests and pharmaceuticals: variation among physicians and effect of cost audit on subsequent use. JAMA 225:%9973, 1973
4. Epstein AM, McNeil BJ: Relationship of beliefs and behavior in
test ordering. Am J Med 80:865-870, 1986
5. Martin AR, Wolf MA, Thibodeau LA, Dzau V, Braunwald E: A
trial of two strategies to modify the test-ordering behavior of
medical residents. N Engl J Med 303:133&1306, 1980
6. Keller RB, Soule DN, Wennberg JE, Hanley EF: Dealing with
variations in use of hospitals: the experience of the Maine
Medical Assessment Foundation Orthopaedic Study Group. J
Bone Joint Surg [Am] 72:77-84, 1990
7. Finkler SA: The distinction between cost and charges. Ann
Intern Med 96102-109, 1982
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cost, two, care, outpatient, intervention, evaluation, arthritis, ancillary, reduced, rheumatoid
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