August 18th, 2013
What Patterns of Change in the Use of Nesiritide Reveal About Hospitals as Learning Organizations
In 2005, safety concerns about nesiritide surfaced in the medical literature, in the media, and in official communiqués from the FDA. To determine how hospitals responded to those concerns and altered their patterns of nesiritide use, my colleagues and I retrospectively analyzed data from the Premier database, including 813,783 hospitalizations for heart failure at 403 hospitals from 2005 to 2010. We applied a growth mixture modeling approach to hospital-level, risk-standardized rates of nesiritide use, to classify hospital groups according to their changing patterns in use of the drug. Our findings, published in JACC: Heart Failure, reveal how hospitals varied in their responses to the new safety information.
Overall, the percentage of hospitalizations for heart failure that involved use of nesiritide declined from 15.4% in 2005 to 1.2% in 2010. An initial sharp drop occurred immediately after safety concerns were publicized, followed by a more gradual decline in subsequent years. That’s not surprising. However, when we analyzed the data at the hospital level, the speed and amplitude of change in nesiritide use varied widely among hospitals. Three distinct groups of hospitals emerged: low-users, fast de-adopters, and slow de-adopters.
The results suggest that common underlying factors within each group of hospitals may explain why they responded so differently. However, we found that these three hospital groups did not differ on traditional hospital characteristics such as size, urban setting, or teaching status. In multivariate regression analysis, none of those standard characteristics was significantly associated with a hospital’s likelihood of being in the slow de-adopter group compared with the other 2 groups.
Those “negative” results were frustrating but not really unexpected. Previous studies have shown that other organizational characteristics — such as team composition (number and type of specialists, inclusion of a pharmacist), internal culture (quality and frequency of communication and collaboration among team members), regulatory context (drug formularies), and availability and use of clinical-decision support systems —have greater impact on medical decision making, evidence-based practice, and hospital performance than do standard hospital categories. However, such organizational characteristics, often called “soft variables,” are not readily available in healthcare databases. Further research using qualitative and mixed methods are therefore required to determine what hospital characteristics actually foster or impede organizational responsiveness.
At this point, some might ask why we analyzed the data at the hospital level rather than physician level. First, hospitalized heart failure patients usually see multiple clinicians because they often have complex disease and multiple comorbidities. Therefore, it is not always possible to identify the prescribing physician. Second, we think the behavior should be attributed to the system structure. For example, it’s important to create an organizational environment where clinicians do not practice in isolated silos but where team building, collaboration, and communication are encouraged. The organization can also provide access to information technology and clinical-decision support systems that help clinicians access timely information, practice evidence-based medicine, and better cope with the uncertainty of accelerating change. This approach is more consistent with the emerging emphasis on systems of care, where the focus shifts from blaming individuals to redesigning how organizations function.
Here are some take-home messages from this study: Changing nature of medical evidence often requires a change in practice. This in turn requires not only access to high-quality, timely information but also a certain degree of “agility” in responding to new evidence. Measuring hospitals’ learning rates, or how quickly and efficiently they respond to new information, could provide important feedback to all stakeholders. It will be crucial to determine what transformations to underlying organizational structure will be associated with greater agility and an improved ability to learn.
As the Greek philosopher Heraclitus once said, “The only constant is change.” In our modern era, the accelerating changes in demographics, economic activity, and technology are challenging our institutions, practices, and beliefs. In my view, the extent to which we are capable of transforming and reinventing our institutions and the way we practice will be the most critical factor in our journey to a high-quality, high-performance healthcare delivery system.
JOIN THE DISCUSSION
Share your views on the study of nesiritide use patterns by Dr. Partovian and her colleagues. Is your institution agile enough to respond to change rapidly and effectively?