Lessons from Mayo Clinic’s Redesign of Stroke Care

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The FINANCIAL — Facing escalating costs of medications and technology, health care patients and providers in the United States continue to search for opportunities to reduce overall costs while maintaining and improving health care outcomes.

At the Mayo Clinic Comprehensive Stroke Center Practice, conducted a project to design and deliver care more customized to the needs of individual patients while reducing cost and resource constraints. It is a risk-stratified approach that could be applied to treating many medical conditions.

The Mayo Stroke Practice used time-driven activity-based costing to study costs associated with alternative protocols for stroke care TDABC uses a bottoms-up approach to identify the actual clinical processes and resources used to care for a patient over a period of time. TDABC works from a process map of a patient’s care pathway, attributing costs to the time of each resource used at each step of the pathway. With this information, clinicians learn how to make more efficient use of high-cost resources, leading to lower total costs while achieving the same or better patient outcomes.

However if one could predict a patient does not need such care, this could save the system, as well as payers, a lot of money. The daily cost of an NSPCU bed — both to the payer and the hospital — averages $500 a day less than an ICU-level care bed, which is multiplied by length of stay. There are also measurable costs “turning over” a hospital bed in terms of both time delays such as patient’s waiting in the emergency department as well as financial expenses in cleaning and sanitizing a room to be ready for the next patient. Similar to the opening moves in a game of chess, which can determine the rest of the game, similar bed logistics can make or break hospital bed flow. So how can one improve both hospital bed flow and improve value-based care in stroke patients?

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Using existing stroke data and TDABC mapping, one can stratify a stroke patient’s true risk for needing or not needing ICU-level care using the National Institutes of Health stroke scale. Historically, a “step-down” unit or progressive care unit was typically used on the back end after ICU-level care for patients too sick and unsafe to send to a regular hospital bed because they might decompensate and end up back in the ICU. Using a NPCU strategy on the front end for some stroke patients is revolutionary in the sense patients are admitted directly from the emergency department after receiving TPA. This reengineering of hospital bed flow allows a relative cost savings without compromising quality and improves the value.

Since 1995, when TPA was FDA-approved to treat stroke patients, the common practice was to monitor these patients in the ICU environment due to concerns for decompensation from intracranial bleeding and complex interventions. Under fee-for-service reimbursement, however, stays in the ICU can incur daily charges up to $2,500, nearly 25% of Medicare’s total reimbursement ($11,000) for TPA treatment.

The Mayo stroke team used the NIH Stroke Scale, which ranges from 0 to 42, to stratify patients into different risk categories and identify those who truly needed ICU-level care. In a trial for intravenous TPA for acute stroke care, reported in 1995 in the New England Journal of Medicine, the average NIHSS score was about 14.

The most severely affected stroke patients had a NIHSS greater than 24 were most likely to need ICU-level care for monitoring. Therefore, Mayo Clinic’s stroke center data showed similar findings and proposed that stroke patients with an NIHSS score of 18 or higher should be monitored in the ICU for the first 24 hours after receiving TPA. Such patients often suffered medical complications that required advanced interventions such as intubation and mechanical ventilation. However, patients with few comorbidities and NIHSS scores of 14 or less had a reduced probability of severe complications that required critical interventions. Care for these patients could potentially be managed and monitored in the lower-cost NSPCU environment.

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The team saw an opportunity to reduce costs based upon how and where patients received care, while still meeting Joint Commission requirements for post-TPA care, by treating low-risk patients in a NSPCU-level bed with a specialized hybrid level of nursing care for the first 12 hours. This risk-stratified care model improved value by delivering equivalent care quality with a lower-cost mix of resources. In addition, the stratification process allowed for better “demand elasticity” of ICU bed utilization.


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