Penn Medicine Princeton Health, Plainsboro, New Jersey, USA.
QURE Healthcare, San Francisco, California, USA.
BMJ Qual Saf. 2019 Oct;28(10):800-808. doi: 10.1136/bmjqs-2018-008829. Epub 2019 Mar 20.
Hospitalist medicine was predicated on the belief that providers dedicated to inpatient care would deliver higher quality and more cost-effective care to acutely hospitalised patients. The literature shows mixed results and has identified care variation as a culprit for suboptimal quality and cost outcomes. Using a scientifically validated engagement and measurement approach such as Clinical Performance and Value (CPV), simulated patient vignettes may provide the impetus to change provider behaviour, improve system cohesion, and improve quality and cost efficiency for hospitalists.
We engaged 33 hospitalists from four disparate hospitalist groups practising at Penn Medicine Princeton Health. Over 16 months and four engagement rounds, participants cared for two patients per round (with a diagnosis of chronic obstructive pulmonary disease [COPD] and sepsis), then received feedback, followed by a group discussion. At project end, we evaluated both simulated and real-world data to measure changes in clinical practice and patient outcomes.
Participants significantly improved their evidence-based practice (+13.7% points, p<0.001) while simultaneously reducing their variation (-1.4% points, p=0.018), as measured by the overall CPV score. Correct primary diagnosis increased significantly for both sepsis (+19.1% points, p=0.004) and COPD (+22.7% points, p=0.001), as did adherence to the sepsis 3-hour bundle (+33.7% points, p=0.010) and correct admission levels for COPD (+26.0% points, p=0.042). These CPV changes coincided with real-world improvements in length of stay and mortality, along with a calculated $5 million in system-wide savings for both disease conditions.
This study shows that an engagement system-using simulated patients, benchmarking and feedback to drive provider behavioural change and group cohesion, using parallel tracking of hospital data-can lead to significant improvements in patient outcomes and health system savings for hospitalists.
住院医师医学的前提是，专注于住院患者治疗的医生将为急性住院患者提供更高质量和更具成本效益的护理。文献显示结果喜忧参半，并指出护理差异是导致质量和成本结果不理想的罪魁祸首。使用经过科学验证的参与和衡量方法，如临床绩效和价值（CPV），模拟患者病例可能会促使医生改变行为、提高系统凝聚力，并提高住院医师的质量和成本效率。
我们邀请了来自四家不同住院医师组的 33 名住院医师参与研究，这些医生在宾夕法尼亚大学医学院普林斯顿健康中心执业。在 16 个月的四个参与轮次中，参与者每轮照顾两名患者（患有慢性阻塞性肺疾病 [COPD] 和败血症），然后接受反馈，随后进行小组讨论。在项目结束时，我们评估了模拟和真实世界的数据，以衡量临床实践和患者结局的变化。
参与者的循证实践显著提高（+13.7%，p<0.001），同时变异减少（-1.4%，p=0.018），这是通过整体 CPV 评分来衡量的。败血症（+19.1%，p=0.004）和 COPD（+22.7%，p=0.001）的主要诊断正确率显著提高，败血症 3 小时包的依从性（+33.7%，p=0.010）和 COPD 的正确入院水平（+26.0%，p=0.042）也有所提高。这些 CPV 变化与住院时间和死亡率的真实世界改善相吻合，同时为两种疾病状况在整个系统中节省了 500 万美元。
这项研究表明，一种使用模拟患者、基准测试和反馈来驱动医生行为改变和团队凝聚力的参与系统，同时平行跟踪医院数据，可以显著改善患者结局和医院系统的节约成本。
