A quality improvement platform developed at Boston Children's Hospital could help health care provider groups continuously improve their medical practice, curbing costs and improving patient outcomes. Successful outcomes associated with the platform, called Standardized Clinical Assessment and Management Plans (SCAMPs) and supported by a consortium of Massachusetts payers, are featured in the May issue of Health Affairs.
SCAMPs start with existing practice recommendations, but are continuously revised as clinicians learn from everyday patient encounters. Recognizing that many clinicians find medical guidelines constraining and not applicable to all situations, SCAMPs permit clinicians to diverge from recommendations as they manage individual patients, provided they document their rationale. The results of this decision-making are then tracked and used to update the guidelines themselves.
"If clinicians want to do something different than what a SCAMP calls for, they have to explain why they're doing it differently," says Boston Children's Hospital Cardiologist-in-Chief James Lock, MD, a co-author on the paper. "The reasons that doctors choose not to follow a SCAMP are extremely important information, and fuel improvement at a rapid clip."
"The SCAMPs platform, which can be applied at any institution for nearly any type of medical problem, could provide the infrastructure needed by health care payers to ensure the success of care and payment reform," Lock adds. The paper documents substantial cost savings, reduced practice variation and improved outcomes after implementation.
The SCAMPs program, started by the cardiovascular program at Boston Children's Hospital in 2009, provides a structured, eight-step approach to innovation that can be applied to nearly any type of medical problem or encounter (see appendix). To date, 49 different SCAMPs have been initiated at Boston Children's and other hospitals, and have involved more than 12,000 patients and more than 25,000 patient encounters, ranging from common outpatient presentations to advanced surgical procedures. Peter Waters, MD, clinical chief of the Orthopedics Center at Boston Children's, is co-chairing a committee to facilitate the spread of SCAMPs institution-wide.
"As clinicians and institutions learn about SCAMPs and what we have accomplished here at Boston Children's, interest in joining our initiative is growing at a remarkable pace," says Michael Farias, MD, MBA, first author on the Health Affairs paper. "Providers of medical care are motivated to do what is best for their patients and, in this environment of healthcare reform, they appreciate that SCAMPs help reduce over-utilization while allowing others to learn from an individual provider's clinical acumen."
Twenty-four new SCAMPs are in development for conditions ranging from management of gastroesophageal reflux to postoperative neurosurgery. Brigham and Women's Hospital has taken the SCAMP model and applied it within its orthopedic surgery department for distal radius fractures, among other conditions. Nearly 20 other health care institutions now collect SCAMPs data (see appendix).
"Tools like SCAMPs are going to be especially important in accountable care, as they let us reduce costs and improve quality at the same time for less frequent conditions, which have been much harder to address with more traditional approaches," says David Bates, MD, MSc, Chief Quality Officer at Brigham and Women's Hospital and a coauthor on the paper. "We have implemented a number of SCAMPs, and it has been a great way to get specialists in particular engaged in care improvement."
The SCAMPs team has documented lowered costs, reductions in practice variation, and improvements in care for several pediatric conditions after implementing the plans. For example:
- Cost reduction
In the Boston Children's Cardiovascular Program, SCAMPs have reduced the average cost of an episode of care by 20 percent for chest pain, 11 percent for patients after the arterial switch operation, 20 percent for hypertrophic cardiomyopathy, 30 percent for aortic regurgitation and 51 percent for aortic stenosis in clinic. In addition, SCAMPs are projected to reduce the average cost of caring for aortic stenosis in the catheterization lab by 33 percent over a 10-year episode of care. Overall, for these six conditions, costs were reduced by an estimated 27 percent, at an estimated $702,000 savings, when compared to pre-SCAMPs patients with the same conditions.
- Reduced practice variation
When a recommended practice was refined through a SCAMP, clinicians were more likely to follow it. For example, a SCAMP for patients with a dilated aortic root examined the recommended practice of referring patients to a geneticist, and found that many referral visits weren't yielding significant new information. When the criteria for referral were tightened, adherence to the recommendation went from 19.6 percent to 75 percent.
- Improved outcomes
When a SCAMP was initiated for balloon valvuloplasty for congenital aortic stenosis, the frequency of "ideal" outcomes rose from 40 percent to 69 percent, while the frequency of "inadequate" results fell from 30 percent to 9 percent.
The SCAMPs initiative is supported by Blue Cross Blue Shield of Massachusetts, Tufts Health Plan, Harvard Pilgrim Health Care and MassHealth through the Payer-Provider Quality Initiative at Boston Children's Hospital. It has been well received by clinicians: in a survey of clinicians from six different institutions, 72 percent favored SCAMPs over clinical practice guidelines, the second most popular quality improvement tool (preferred by 12 percent).
"The SCAMPs program has been able to build clinically informed treatment paradigms for both complex and routine conditions," says Joel Rubinstein, MD, Medical Director for Network Medical Management and Behavioral Health at Harvard Pilgrim Health Care, a health plan that has provided support to SCAMPs. "Variation and unnecessary interventions have been reduced with improvements in efficiency and quality. Health plans such as Harvard Pilgrim Health Care welcome the SCAMPS program for these reasons, and expect it will lead to better care for our members and the community."
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