Physicians can change outcomes by taking a look at cost-effectiveness

Focusing on data improves discharge patterns

What does it take to change physician behavior? According to the prevailing wisdom (and some medical studies), education, feedback, and quality improvement programs bring slow movement. Yet a more optimistic picture of physician behavior emerged from a study by Christopher J. Kwolek, MD, a vascular surgeon and assistant professor of surgery at the University of Kentucky College of Medicine in Lexington. He found that simply discussing and focusing on cost-effectiveness could change physician discharge habits, leading to a 21.6% drop in the average length-of-stay and average 6.5% reduction in medical costs.

"It is a misperception that physicians are reticent to change," asserts Kwolek, who presented his findings at the 1997 Clinical Congress of the Chicago-based American College of Surgeons in October. "If you give people proper information and give them a choice to participate or not participate, most people will choose to control their own environment."

Kwolek arrived in Kentucky about 21¼2 years ago after training in Boston. He found a market that was much less developed in terms of managed care. But his three colleagues in vascular surgery agreed that managed care was rapidly gaining ground.

They decided to work with administration at the Chandler Medical Center in Lexington to hire a case manager and implement pathways, thus creating greater standardization of care, outcomes monitoring, and some cost savings.

Kwolek collected some initial data on costs, charges, and length of-stay from fiscal year 1994. He shared it with his colleagues as they began to draft the proposal for the case management program. "It was just a series of meetings with the four of us talking about it," he says. "We didn’t have a formal review process. We did not get monthly reports."

A year later, the physicians reviewed cost and length-of-stay data for fiscal year 1996. Kwolek controlled for patient age, number of comorbid conditions, and the types of cases and found significant improvements. For example, the average length of stay declined from 11.9 days to 9.3 days. Readmission rates remained steady; the use of home health services rose from 15% in 1994 to 24% in 1996.

"Just the fact that we were made aware of the cost data and became more conscientious about that, we were able to use better discharge planning," says Kwolek. "We were able to significantly decrease our cost and length of stay without the formal programs that you usually think of."

Kwolek and his colleagues are moving forward with the case management program. They plan to collect further data, including patient satisfaction information, and determine the program’s impact.