Small scale health-care reform


Physician applies business training to cut procedure costs


By Gigi Wood


A University of Iowa Hospitals and Clinics doctor has found a way to reform health care in his own department.


Dr. Mark Iannettoni is professor and head of cardiothoracic surgery and physician head of the Heart andVascularCenterat UIHC. He also has an MBA.


He has combined his knowledge, training and experience in esophagus surgery with business to reduce the cost and patient stay for those who receive an esophagectomy, an operation that removes the esophagus in patients, typically those with esophagus cancer.


Changes to the procedure at UIHC have cut costs from $67,000 to $21,000. Surgery time was trimmed from six hours to two to three hours.


“If you look at the most expensive place in the hospital, it’s the operating room; it’s anywhere from $42 to $72 a minute depending on how you calculate it,” Mr. Iannettoni said. “So we cut down on the operating time with the use of some newer technologies, staplers and some devices, where instead of suturing, we actually sear shut the vessels. So that cuts down on time.”


The patient hospital stay has been reduced from 12 to 14 days to three to five days. Meanwhile, patient safety and the surgery success rate has remained stable.


To achieve this, Mr. Iannettoni decided to take a business model approach to the procedure, to look for ways to improve efficiencies. But there is one element that was critical to the entire process, he said.


“The key thing in this, the most important aspect of this is we have a nurse coordinator who provides a continuum of care for (patients),” he said. “I think the biggest reason people end up staying in the hospital or are reluctant to go home is they don’t have a contact person anymore.


Kelley McLaughlin, nurse coordinator in UIHC’s cardiothoracic surgery department, visits with patients during a doctor visit before the surgery, during the pre-operative process and while they are recovering in the hospital.


“Then they have a face to associate with when they go home with a phone number on the other side,” Mr. Iannettoni said. “So it’s somebody who actually knows what’s going on with them. If you had a person you could call with any problem after you’ve had an operation, who you already have an established relationship with, you feel much more comfortable. It’s this fear of, ‘OK, now I’m gone, who’s my lifeline?’ And that’s the only reason this (streamlined procedure) works.”


Mr. Iannettoni said the streamlined process is a result of analyzing the esophagectomy procedure. Many elements of the procedure had been done for years, because doctors in the past had done those things.


“The people who taught you, you never change what they did because it worked for them,” he said. “So we looked at process improvement and it’s one of the things I was very interested in after business school.”


Previously, patients were kept on a breathing ventilator after surgery for three days.


“We looked at, why don’t we take people off the ventilator for three days? Well, because that’s the way we always did it,” he said. “So we decided we’re going to take them off the ventilator in one day.”


The decisions that changed the procedure were made using patient safety and best outcomes data. Because of modern technology and sophistication of the procedure, patients no longer need to be on a ventilator for three days.


“I think one of the things we need to look at is how can we provide more health care for more people with the same number of problems, which is really a problem,” Mr. Iannettoni said. “We’ve got a lot of waste and a lot of redundant processes that don’t necessarily make things better, safer or improve quality of care, in fact they may do just the opposite.”


Patients also no longer need to stay in the intensive care unit immediately after the operation, he said.


“We realized the reason we sent them to the (intensive care) unit is because we weren’t comfortable, not that we had post-op bleeding that happens,” he said. “So we stopped sending patients to the intensive care unit for three days. And when you cut that stay out, that drops everything by almost $15,000.”


Previously, patients were kept at the hospital for seven to 10 days after surgery to make sure there were no leaks, or other problems.


“All of those leaks, almost reliably, occurred within the first three to five days, so after that they were just staying here while we were observing them,” Mr. Iannettoni said. “So we decided we didn’t need those extra two to three days in the hospital just for observation. And to be quite honest, patients are much more comfortable at home anyway.”


Patients initially are hesitant about the reduced hospital stay, he said.


“If it’s presented to the patient that you know this is just a surgery and our process is really good here and it’s really not that big of a deal that you’re going to go home in five days, once the patient from the pre-operative stage starts thinking about that, they start to realize that it’s not such a big deal,” he said.


The new processes did not take long to implement at UIHC, he said.


“People are very willing to do things as long as you’re going to look at it objectively and have good data to follow through on it,” Mr. Iannettoni said.


Total artificial heart transplant success


Iowa’s first total artificial heart recipient was discharged from UIHC Aug. 9. UIHC is the only hospital in the state to perform the procedure, and one of less than 30 hospitals globally.


According to the device manufacturer, 59-year-old Richard Whittington of Geneseo, Ill., was the first person in theMidwestto be discharged from a hospital after receiving the procedure and transplant.


The SynCardia temporary Total Artificial Heart is the world’s first total artificial heart currently approved as a bridge to transplant by the Food and Drug Administration for people dying from end-stage heart failure affecting both sides of the heart. The artificial heart replaces both failing heart ventricles and the four heart valves, eliminating the symptoms and source of end-stage biventricular heart failure in transplant-eligible patients. The artificial heart has been in development for more than 20 years and offers a better success rate, at 75 percent, than other methods, said Dr. Jennifer Goerbig-Campbell, a UIHC cardiologist.


“We have this option we can offer to people now, we can essentially pull it off the shelf when they have no other options,” she said. “This is a device that has offered an option for life for people who don’t have another option at that point and who would otherwise die, so it’s a great thing.”


It is anticipated that UIHC will perform the procedure one to five times a year.


Blinding eye disease advance


UI researchers have found a new genetic cause of the blinding eye disease retinitis pigmentosa (RP) and, in the process, discovered a new version of the message that codes for the affected protein.


The UI researcher’s study was published online Aug. 8 in the Proceedings of the National Academy of Sciences (PNAS) Early Edition. It suggests that the mutation may be a significant cause of RP in people of Jewish descent. The findings also lay the groundwork for developing prevention and treatment for this form of RP using a combination of genetic testing, gene therapy and cell replacement approaches.


RP is an uncommon, inherited blinding eye disease that affects about 1 in 4,000 people in theUnited States. It is thought to be caused by mutations in more than 100 different genes, only half of which have been identified.


Facebook for medication reminders


Dr. Patrick Brophy, director of UIHC’s Division of Pediatric Nephrology, Dialysis and Transplantation at the children’s hospital, developed new software that uses Facebook to remind young patients about taking medications.


“Teenagers and young adults do pretty well when it comes to taking their medications initially after a transplant, but the largest number of kidney failures in this age group comes from noncompliance,” he stated in a press release.


The application, called Iowa MedMinder, is customized to each patient’s circumstances and creates a pop-up box listing all of the medications to be taken that day. The box will appear on their Facebook page and the patient clicks on the medications that have been taken. That information is then relayed back to the primary physician.