Institute for Healthcare Improvement: Appropriate Use of Specialty Care Services

About the Appropriate Use of Specialty Care Services Prototyping Initiative

In Summer 2008, IHI conducted a research and development project that included an extensive literature search and outreach to organizations engaged in improvement work to better understand the contributors to the overuse of specialty services and to develop strategies for the appropriate use of services.

Since the initial phase of work, the IHI R&D team has developed this content into a framework for a prototyping initiative. For more information about prototyping and the R&D process at IHI, please visit IHI 90-Day R&D Process. IHI has found that prototyping and subsequent dissemination are greatly accelerated by bringing innovators together with content and improvement experts to share ideas and experiences during the process of discovery.

We are currently seeking interested and capable organizations from all over the world to join this effort.

The Best Care, for the Whole Population, at the Lowest Cost

The annual cost for healthcare in the United States is about $2.2 trillion with up to 30% of the total health care dollars, or $700 billion, representing care that could be eliminated without reducing quality. Research has shown a wide variation in utilization of certain tests and procedures without differences in quality between high and low utilizing regions. The majority of the variation is not explained by differences in rates of illness, fees, or other population factors. Variation occurs in procedures for which there is often no clear “best option” because of multiple trade-offs between quality of life and risk considerations.

IHI has developed a model for appropriate use of specialty services including these key elements:

Engagement of physicians as partners in both interpreting the meaning of variation and planning interventions.
Engagement of patients in shared decision making through use of decision aids.
Local adoption, adaptation or development of appropriateness criteria for selected procedures.
Development of service agreements between primary and specialty care to assure coordination and consistency of care throughout the patient “journey”.
Design and improvement of care processes for efficiency and reliability.

The National Priorities Partnership (NPP) of the National Quality Forum has set a series of goals for transformation of healthcare including nine areas where utilization can be reduced without impacting quality. For the prototyping initiative, IHI will focus efforts within two of these nine areas:

Diagnostic procedures: cardiac computed tomography (non-invasive coronary angiography and coronary calcium scoring); lumbar spine MRI prior to conservative therapy, without red flags; uncomplicated chest/thorax CT screening, bone or joint x-ray prior to conservative therapy, without red flags; chest x-ray, preoperative, on admission, or routine monitoring; and endoscopy.
Procedures: spine surgery, percutaneous transluminal coronary angioplasty (PTCA)/Stent, knee/hip replacement, coronary artery bypass graft (CABG), hysterectomy, prostatectomy.

IHI is launching prototyping under the umbrella of our Triple Aim Initiative , and seeks interested and capable organizations to join this effort.

Opportunities to Learn More

Please address inquiries about this Triple Aim initiative to Courtney Kaczmarsky at ckaczmarsky@ihi.org.

Reducing Costs Through the Appropriate Use of Specialty Services:
This IHI white paper presents a framework that is being tested by teams participating in the prototyping initiatve.

Listen to the April 23, 2009 informational call, led by faculty Carol Beasley, regarding Specialty Care prototyping and other Triple Aim programs.

Read Atul Gawande's article, "The Cost Conundrum," about the overuse of medical care.

Find more information about IHI's Triple Aim initiative.

Download the Triple Aim initiative brochure.