Does Choosing Wisely Work?

The articles below, having met the standards of peer review, illustrate the outcomes of Choosing Wisely implementation in health systems across the country.

  • Dressler, R, Dryer, MM, Coletti, C, Mahoney, D, Doorey, AJ. Altering overuse of cardiac telemetry in non-invasive care unit settings by hardwiring the use of American Heart Association Guidelines. JAMA Intern Med. 2014 Nov; 174 (11):1852-4.
    Christiana Care Health System changed their order set so that all telemetry orders must include the clinical indication. Orders for most indications were given a standardized time limitation, automatically expiring at 24 or 48 hours based on American Heart Association guidelines. Physicians were alerted prior to discontinuation of telemetry and were prompted to reorder if needed. The initial implementation period (March-August 2013) resulted in immediate and sustained decreases in telemetry orders and telemetry duration of 43% and 47%, respectively. The hospital saw 70% reduction in the daily number of patients monitored with telemetry. Daily cost savings in telemetry delivery were estimated to be $13,199. Adverse events did not increase following the intervention.
  • Felcher AH, Gold R, Mosen DM and Stoneburner AB. Decrease in unnecessary vitamin D testing using clinical decision support tools: Making it harder to do the wrong thing.  J Am Med Inform Assoc. 2017 Feb 19.
    Northwest Permanente evaluated how rates of vitamin-D screening changed after it implemented three clinical decision support (CDS) tools in the electronic health record (EHR) of a large health plan: a new vitamin-D screening guideline, a hard stop alert that requires clinician acknowledgement of current guidelines to continue ordering the test and a modification of laboratory ordering preference lists that eliminates shortcuts. The institution assessed rates of overall vitamin-D screening and appropriate vitamin-D screening six months pre- and post-intervention. Vitamin-D screening rates decreased from 74.0 tests to 24.2 tests per 1000 members (P < .0001). Appropriate vitamin-D screening tests increased from 56.2% to 69.7% (P < .0001) and inappropriate screening tests decreased from 43.8% to 30.3% (P < .0001).
  • Hasler, S, Kleeman, A, Abrams, R, Kim, J, Gupta, M, Krause, MK, Johnson, TJ. Patient safety intervention to reduce unnecessary red blood cell utilization. Am J Manag Care. 2016 Apr;22(4):295-300.
    In May 2013, Rush University used academic safety conferences, e-mail safety alerts, and feedback to providers on global blood product utilization to reduce unnecessary red blood cell (RBC) use. Blood-product use started to decline after the AABB guideline, but dropped much further after the focused, local interventions were implemented. The proportion of patients receiving a transfusion decreased from 12.6% prior to the AABB guideline to 8.8% after the intervention (P < .001). The percent of total blood use with a hemoglobin level above 8 g/dL decreased from 20.2% to 12.4%; the total units of RBCs transfused per 100 discharges also decreased from 33.4 to 21.7. The direct RBC costs per discharge dropped from $61.60 to $39.70.
  • Iams, W, Heck, J, Kapp, M, Leverenz D, Vella M, Szentirmai E, Valerio-Navarrete I, Theobald C, Goggins K, Flemmons K, Sponsler K, Penrod C, Kleinholz P, Brady D, Kripalani S. A multidisciplinary house staff-led initiative to safely reduce daily laboratory testing. Acad Med. 2016 Jun;91(6):813-20.
    Vanderbilt University Medical Center’s Choosing Wisely steering committee, led by housestaff with faculty advisors, sought to reduce unnecessary daily basic metabolic panel (BMP) and complete blood count (CBC) testing on inpatient general medicine and surgical services. Intervention services received a didactic session followed by regular data feedback with goal rates and peer comparison. The mean number of BMP tests per patient decreased by an additional 0.23 on medical housestaff and 0.15 on hospitalist intervention services. Daily CBC tests decreased by an additional 0.28 on medical housestaff, 0.08 on hospitalist, and 0.12 on surgical housestaff intervention services. Patients with lab-free days (0 labs ordered in 24 hours) increased by an additional 4.1 % on medical housestaff and 9.7% on hospitalist intervention services. There were no adverse changes in length of stay or intensive care unit transfer, in-hospital mortality or 30-day readmission rates.
  • Kost A, Genao I, Lee JW, Smith SR.  Clinical decisions made in primary care clinics before and after Choosing Wisely. J Am Board Fam Med. 2015 Jul-Aug;28(4):471-4.
    The National Physicians Alliance compared clinical decisions made for five Choosing Wisely recommendations over two 6-month time periods before and after the campaign launch and an educational intervention to promote it at three primary care residency clinics. The rate of recommendations adherence was high (93.2%) at baseline but did significantly increase to 96.5% after the launch. These findings suggest primary care physicians respond to training and publicity in low-value care, though further research is needed.
  • Kruger, JF, Chen, AH, Rybkin, A, Leeds, K, Guzman, D, Vittinghoff, E, Goldman, LE.  Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering. BMJ Qual Saf. 2016 Dec;25(12):977-985.
    San Francisco Health Network, an urban safety-net health system, displayed radiation exposure information for CT and cost information for CT, MRI and ultrasound on an electronic referral system for outpatient ordering. The organization assessed differences in the numbers of outpatient CT scans and MRIs per month relative to ultrasounds before and after the intervention, and evaluated primary care clinicians’ responses to the intervention. From 2011 to 2014, the ratio of CTs to ultrasounds decreased by 15%, the ratio of MRIs to ultrasounds declined by 13%. Sixty three percent of the 300 invited clinicians completed a web-based survey in 17 clinics. Eighty-one percent noticed the radiation exposure information and 83.2% noticed the cost information. Clinicians believed radiation exposure information was more influential than cost information: when unsure clinically about ordering a test (radiation=69.7%; cost=46.4%), when a patient wanted a test not clinically indicated (radiation=77.5%; cost=54.8%), when they had a choice between imaging modalities (radiation=77.9%; cost=66.6%), in patient care discussions (radiation=71.9%; cost=43.2%) and in trainee discussions (radiation=56.5%; cost=53.7%). Resident physicians and nurse practitioners were more likely to report that the cost information influenced them (p<0.05).
  • Larochelle, MR, Knight, AM, Pantle, H, Riedel, S, Trost, JC. Reducing excess cardiac biomarker testing at an academic medical center. J Gen Intern Med. 2014 Nov;29(11):1468-74.
    At Johns Hopkins Bayview Medical Center, a multimodal intervention was introduced August through October 2011 that included dissemination of an institutional guideline and changes to the computerized provider order entry system. Twelve months following the intervention, the institution estimated that guideline-concordant ordering of cardiac biomarkers increased from 57.1% to 95.5%, an absolute increase of 38.4%. The intervention also led to a 66% reduction in the number of tests ordered, and an estimated $1.25 million decrease in charges over the first year. At 12 months, there was an estimated absolute increase in incidence of primary diagnosis of ACS of 0.3% compared with the expected baseline rate.
  • Matulis, J, Liu, S, Mecchella, J, North, F, Holmes, A. Choosing Wisely: A Quality Improvement Initiative to Decrease Unnecessary Preoperative Testing. BMJ Qual Improv Rep. 2017 May 23;6(1).
    At Dartmouth-Hitchcock Medical Center, a multi-disciplinary team used a micro-systems approach to analyze the existing process and formulate a rapid-cycle improvement strategy to reduce routine preoperative testing. The improvement efforts focused on implementation of a Nurse Practitioner and Physician Assistant (Associate Provider) clinic to incorporate standardized protocols for preoperative assessment. Plan-Do-Study-Act (PDSA) cycles included creation of a dedicated Associate Provider-run preoperative clinic, modifying and operationalizing a scheduling scheme, and creating and implementing Electronic Health Record (EHR) tools. The institution used Statistical Process Control (SPC) methods to analyze time-ordered data for the usual care process and to compare performance with the novel preoperative clinic. The Associate Provider-preoperative clinic showed unnecessary testing rates of 4% compared with 23% in the usual care cohort (p<.001) within three months of implementation. When testing rates across the entire division were analyzed, there was no significant change. In our GIM division this preoperative clinic was effectively staffed with Associate Providers.
  • Pittenger, K, Williams, BL, Mecklenburg, RS, Blackmore, CC. Improving acute respiratory infection care through nurse phone care and academic detailing of physicians. J Am Board Fam Med. 2015 Mar-Apr;28(2):195-204.
    Virginia Mason Medical Center implemented nurse phone care and provider academic detailing to lower inappropriate antibiotic usage and unnecessary provider visits. To evaluate the intervention, the institution performed a retrospective time-series study and cost analysis with 118 providers at seven sites. The main outcomes were: (1) antibiotic rate, (2) provider visits avoided, and (3) cost savings from the payer and health care system perspectives. Data were collected for January 2, 2010 to November 30, 2013, with the interventions occurring on March 1, 2012. There were 54,283 acute upper respiratory infection visits, and the nurse phone consultation involved 13.8% (3,289 of 23,769) of care episodes. The intervention was associated with a 16.5% absolute decrease in antibiotic rate, after adjustment. Post intervention, 1983 of 23,769 (8.3%) episodes did not require any provider visit (1133 per year). Single institution cost savings to payers exceeded $175,000.
  • Schondelmeyer, AC, Simmons, JM, Statile, AM, Hofacer, KE, Smith, R, Prine, L, and Brady, PW. (2015). Using quality improvement to reduce continuous pulse oximetry use in children with wheezing. Pediatrics. PEDIATRICS. 2015 April;135(4).
    Cincinnati Children’s Hospital Medical Center implemented a multimodal intervention to reduce continuous pulse oximetry (CPOx) on one unit of a children’s hospital. The institution developed consensus-based criteria for CPOx discontinuation. Interventions included education, a checklist used during nurse handoff and discontinuation criteria incorporated into order sets. Data collection included time until medically ready, ICU transfers, hospital revisits and medical emergency team calls on both units. Impact of interventions was assessed by using run charts and statistical process control charts. Also a second unit without interventions was followed to assess for secular trends and negative consequences of shorter monitoring. Median time per week on CPOx after meeting goals decreased from 10.7 hours to 3.1 hours on the intervention unit. Median time per week on CPOx on the control unit decreased from 11.5 hours to 6.9 hours. There was no decrease in time until medically ready on either unit. The percentage of patients needing transfer, revisit, or medical emergency team call was similar on both units.
  • Stinnett-Donnelly, JM, Stevens, PG, Hood, VL. Developing a high value care programme from the bottom up: a programme of faculty-resident improvement projects targeting Harmful or Unnecessary Care. BMJ Qual Saf. 2016 Nov;25(11):901-908.
    Using a grassroots approach, the University of Vermont Medical Center asked faculty to submit ideas for high-value care projects which would identify tests and treatments that should be performed less frequently. Using Choosing Wisely lists as examples, projects had to meet the following criteria: (1) be evidence-based; (2) be reliably measured electronically; (3) have a meaningful impact on reducing harm, cost or patient inconvenience; (4) not increase physician workload; and  (5) involve trainee education and more than one group or division. Implementation strategies included educational platforms and changes to the current process or electronic health system. The chair noted that the staff was very reflective on what made their program successful. Interventions on seven projects were completed, and key outcomes included: (1) a 72% reduction in the use of blood urea nitrogen (BUN) and creatinine lab testing in patients with end stage renal disease who were on hemodialysis and hospitalized; (2) a 90% reduction in DEXA screening on women 65 and older without clinical risk factors for osteoporosis; and (3) a 71% reduction in the use of portable chest X-rays in mechanically ventilated patients who were not intubated that day and did not have a procedure performed.
  • Yarbrough, PM, Kukhareva, PV, Horton, D, Edholm, K, Kawamoto, K. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs. J Hosp Med. 2016 May;11(5):348-54.
    University of Utah Health Care implemented a multifaceted quality improvement initiative in a hospitalist service including education, process change, cost feedback and financial incentive. A total of 6,310 hospitalist patient visits (intervention group) were compared to 25,586 non-hospitalist visits (control group). Among the intervention group, the unadjusted mean cost per day was reduced from $138 before the intervention to $123 after the intervention (P < 0.001), and the unadjusted mean cost per visit decreased from $618 to $558 (P = 0.005). The ITS analysis showed significant reductions in cost per day, cost per visit and the number of BMP, CMP and CBC tests per day (P = 0.034, 0.02, <0.001, 0.004, and <0.001). LOS was unchanged and 30-day readmissions decreased in the intervention group.
  • Raja, AS, Venkatesh, A, Mick, N, Zabbo, CP.  “Choosing Wisely” Imaging Recommendations: Initial Implementation in New England Emergency Departments. West J Emerg Med. 2017 Apr;18(3):454-8.
    This survey study was exempt from institutional review board review. In 2015, we mailed surveys to 195 hospital-affiliated EDs in all six New England states to determine whether they had implemented Choosing Wisely-focused interventions in 2014. Initial mailings included cover letters denoting the endorsement of each state’s ACEP chapter, and we followed up twice with repeat mailings to non-responders. Data analysis included descriptive statistics and a comparison of state differences using Fisher’s exact test. A total of 169/195 (87%) of New England EDs responded, with all individual state response rates >80%. Overall, 101 (60%) of responding EDs had implemented an intervention for at least one Choosing Wisely imaging scenario; 57% reported implementing a specific guideline/policy/clinical pathway and 28% reported implementing a computerized decision support system. The most common interventions were for chest computed tomography (CT) in patients at low risk of pulmonary embolism (47% of EDs) and head CT in patients with minor trauma (45% of EDs). In addition, 40% of EDs had implemented provider-specific audit and feedback, without significant interstate variation (range: 29–55%).

Check out additional implementation stories in the Updates From The Field archive.