The Integrated Healthcare Association (IHA), a nonprofit multi-stakeholder group focused on improving quality, accountability and affordability, lead a project promoting appropriate care in California. IHA partnered with Sharp Rees-Stealy Medical Group in San Diego County, Sutter Health in Sacramento/Central Valley/San Francisco Bay, the California chapter of the American College of Physicians (ACP-CA), the Center for Healthcare Decisions (CHCD) and Blue Shield of California (BSC) to engage providers and consumers in their efforts to reduce overuse.
Their project aimed to reduce:
- Utilization of antibiotics for adults with acute bronchitis;
- Imaging for nonspecific low back pain;
- Imaging for uncomplicated headache;
- Pre-operative stress testing for patients scheduled to undergo low or intermediate-risk non-cardiac surgery;
- Repetitive complete blood count and chemistry testing for hospitalized patients.
Clinical interventions were led by the two provider partners, Sharp Rees-Stealy and Sutter Health. Sharp Rees-Stealy formulated a physician decision-support strategy with printed materials and computer-based, point-of-care tools, including a physician “peer-to-peer consult” process and clinician education. Consumer-facing strategies included broad dissemination of the “5 Questions” wallet cards to all new members. Sutter Health targeted variation reduction through in-person meetings with participating physicians to engage clinicians in a group setting, supported by comparative performance data at the physician level. Following the facilitated meetings, Sutter Health monitored changes in the targeted services, and delivered updated data to each clinician on a monthly basis.
To illuminate the citizen perspective on overuse and the most acceptable ways to reduce wasteful care, the Center for Health Care Decisions conducted ten deliberative discussions with groups of insured Californians (through separate funding). Findings from the “Doing What Works” project are summarized in a report and were featured on a May 2016 webinar. Blue Shield of California shareed Choosing Wisely materials with its 3.4 million members through print, online and mobile media. ACP-California engaged in a variety of communication activities with its 9,300 internist members about the campaign, including conference sessions, newsletters, and a monthly clinical case that highlights an overuse scenario.
In addition to coordinating and supporting the project partners, IHA promoted the Choosing Wisely campaign through regular features in newsletters that reach 10,000 recipients, and discussed overuse in forums such as IHA’s Stakeholders Meeting. The September 2016 IHA Stakeholders Meeting featured approaches to tackling overuse of imaging through Choosing Wisely through an array of interventions – including clinical decision support. All of the project partners participated in a related initiative that IHA manages: Smart Care California (SCC) is a statewide initiative led by Covered California, CalPERS, and the Department of Health Care Services, which collectively cover over 15 million Californians.
- IHA Senior Vice President of Programs and Policy, Jill Yegian, PhD on the organization’s plans for implementation
Stories of Success
A Philosophy of Reduction in San Diego
Sharp Rees-Stealy Medical Group has been recognized as a high-quality medical group for more than 10 years, which leaders credit to the “The Sharp Experience.” The entire organization is built around caring for patients as people, taking a holistic view and working to improve the health of the entire community.
Partnering with California’s Integrated Healthcare Association, Sharp worked to develop clinical guidelines for all physicians in the organization to help them choose when certain tests, like imaging for routine low back pain or prescriptions for antibiotics, are appropriate. Developed amongst peer physicians, this guide helped to capture data on which physicians in their organization might be outliers and have opportunities for improvement.
“Sometimes it is easier for an already busy physician to write a prescription for an antibiotic or order imaging than to spend time with a patient and talk about why that might not be necessary,” said Parag Agnihotri, MD, Medical Director for Continuum of Care at Sharp Rees-Stealy Medical Group. “It requires a meaningful dialogue between the patient and the physician around why this test, or why this treatment should not be done. But in our organization, we have worked to foster an environment where transparent data is welcome, and we really are starting to see change.”
The group engaged clinic providers at 19 sites including primary care offices, urgent care settings, cardiology, physical medicine and neurology. All providers were sent educational material reminding them when antibiotics for low-back pain imaging is appropriate or inappropriate. Primary care physicians (PCPs) were sent their individual rates in all three objective measures, along with patient details for review. These reports also introduced and tied in patient-friendly resources from Consumer Reports on both topics. Sharp also established a physician “peer-to-peer consult” process to help determine when cardiac stress tests were appropriate and when more conservative care was recommended. These efforts helped Sharp reduce both their use of antibiotics and their use of cardiac stress testing by approximately 5%.