A sequential intervention achieved significant reductions in ICU albumin use and cost savings without changes in patient outcomes, supporting the combination of financial and nonfinancial strategies to align providers with evidence-based practices.

Objective Healthcare systems strive to provide quality care at lower cost. Arterial blood gas testing (ABGs), chest radiographs (CXRs), and red blood cell transfusions (RBCs) provide an important example of opportunities to reduce excess resource utilization within the ICU. We describe the effect of a multifaceted quality improvement program designed to decrease avoidable ABGs, CXRs, and RBCs utilization on utilization of these resources and patient outcomes. Design Prospective pre-post cohort study Setting Seven ICUs in an academic healthcare system Patients All adult ICU patients admitted to study ICUs during consecutive baseline (n=7,357), intervention (n=7,553), and follow up (n=7,657) years between September 2010 and August 2013. Interventions A multifaceted quality improvement program including provider education, audit and feedback, and unit-based provider financial incentives targeting ABG, CXR, and RBC utilization. Measurements and Main Results The primary outcome was the number of orders for ABGs, CXRs, and RBCs per patient. Compared to the baseline period, unadjusted ABG, CXR, and RBC utilization in the intervention period was reduced by 42%, 26%, and 17%, respectively (p<0.01). After adjusting for potentially relevant patient factors, the intervention was associated with 128 fewer ABGs, 73 fewer CXRs, and 16 fewer RBCs per 100 patients (p<0.01). This effect was durable during the follow up year. This reduction yielded an approximate net savings of $1.5 M in direct costs over the intervention and follow-up years after accounting for the direct costs of the program. Unadjusted hospital mortality decreased from 7% in the baseline period to 5.2% in the intervention period (p<0.01). This reduction remained significant after adjusting for patient factors (OR= 0.43, P<0.01). Conclusions Implementation of a multifaceted quality improvement program including financial incentives was associated with significant improvements in resource utilization. Our findings provide evidence supporting the safety, effectiveness, and sustainability of incentive-based quality improvement interventions.

We did not identify an association between antibiotic appropriateness and 30-day mortality, hospital LOS, or ICU LOS in post-LT recipients.

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