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."
SCAMPs results 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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Authors of the paper were: Michael Farias, MD, MBA, senior resident in pediatrics in the Boston Combined Residency Program at Boston Children's Hospital and Boston Medical Center; Kathy J. Jenkins, MD, MPH, Senior Vice President and Kobren Family Chair in Safety and Quality at Boston Children's Hospital; James E. Lock, MD, Cardiologist-in-Chief at Boston Children's; Rahul H. Rathod, MD, Department of Cardiology at Boston Children's; Jane W. Newburger, MD, MPH, Associate Cardiologist-in-Chief for Academic Affairs at Boston Children's; David W. Bates, MD, MSc, Director of the Center for Patient Safety Research and Practice at Brigham and Women's Hospital; Dana G. Safran, ScD, Senior Vice President for Performance Measurement and Improvement at Blue Cross Blue Shield of Massachusetts; Kevin G. Friedman, MD, Department of Cardiology at Boston Children's Hospital; and Joshua Greenberg, JD, MA, Vice President of Government Relations at Boston Children's.
Founded in 1869 as a 20-bed hospital for children, Boston Children's Hospital is the primary pediatric teaching hospital of Harvard Medical School and the largest provider of health care to Massachusetts children, with 395 pediatric and adolescent inpatient beds and 228 outpatient programs. Boston Children's is home to many clinical discoveries, innovations and quality improvement initiatives, and houses the world's largest research enterprise based at a pediatric medical center, with more than 1,100 scientists. For more information about the hospital, visit http://www.childrenshospital.org/newsroom.
APPENDIX
Eight steps for starting a SCAMP around a medical condition
Courtesy James Lock, MD, cardiologist-in-chief, Boston Children's Hospital
Review the literature about the disorder and prior patient experience to establish a background position paper as a starting point. Obtain consensus on which patients to include in the SCAMP, how they will be assessed, and the starting algorithm for managing them. Formulate "plausible findings" reflecting what the group hopes to learn about managing the disorder. Develop data forms and electronic tools to capture information as the SCAMP is implemented. Pilot the SCAMP at a few sites, enrolling the appropriate patients. Via the clinician and a data coordinator, gather targeted clinical data including information from patient medical records, any divergence from existing care plans and the reasons for the divergence. After a predetermined interval (generally 6 to 12 months, or after 200 patients are enrolled), analyze the SCAMP data and diversions from practice guidelines. Based on the analysis and updates in the literature, iteratively modify and improve the SCAMP, subsequently tracking the outcomes.
Institutions participating in SCAMPs as of 4/1/2013 Baystate Medical Center (Springfield, MA) Boston Children's Hospital Boston Medical Center Brigham and Women's Hospital (Boston) Child Heart Associates (Worcester, MA) Children's Hospital of Wisconsin (Milwaukee) Children's National Medical Center (Washington, DC) Connecticut Children's Medical Center (Hartford) Dartmouth-Hitchcock Medical Center (Manchester, NH) Harvard Vanguard Medical Associates (Boston) Hasbro Children's Hospital (Providence) Lancaster General Hospital (Lancaster, PA) Maine Medical Center (Portland) Massachusetts General Hospital Pediatric Endocrine Society University of California-San Francisco Benioff Children's Hospital University of Massachusetts Medical Center (Worcester) University of Vermont Medical Center (Burlington) Yale Medical Center (New Haven, CT)
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