When Scott Pugel, MD, a pediatrician and Physician Program Director of Resource Stewardship for Kaiser Permanente Georgia, began talking with his colleagues in 2013 about exploring overuse of medical services in ambulatory care within their medical group, he had no real sense of what would be found.
Working with data specialists, Pugel discovered that substantial variation existed in the frequency with which non-beneficial services were provided by more than 180 physicians across 25 medical offices serving roughly 300,000 health plan members.
That led his team to propose a change management strategy that focused on shifting clinical behavior through implementation of four Choosing Wisely guidelines, the first major project in his new role as the chief champion of resource stewardship at KP Georgia.
“We ran the data to see where opportunities existed to minimize low-value care,” said Pugel, whose intervention project resulted significant and sustained reductions in complete blood counts (CBCs) and electrocardiograms (EKGs) during routine physical exams, bone density scans among women and men without risk factors, and imaging for uncomplicated headaches.
Pugel said he was not surprised to uncover issues with overuse even though KP Georgia had a history of successful quality improvement projects in ambulatory care, including a performance improvement project on HEDIS (Healthcare Effectiveness Data and Information Set) measures addressing the use of imaging for nonspecific low-back pain.
For instance, the baseline proportion of routine physical exam visits for which an EKG was ordered ranged from 5 percent to 95 percent across clinicians before the study, conducted from January 2013 to December 2016. Overall use of EKGs declined from an average of 15.9 percent to 0.3 percent as a result of the project.
The implemented recommendations, selected by the chief of adult ambulatory medicine, were from the American Academy of Family Physicians, the American College of Radiology, and the College of Family Physicians of Canada. Implementation began in May 2014 and included monthly reporting, which ended in January 2016.
“Medicine is extremely wasteful, and with the cost of medicine escalating it’s not sustainable for patients to pay the costs. It’s estimated that about 25 percent of what we do in medicine is waste. That’s an awful lot of money that could be saved for everyone,” said Pugel.
Besides Pugel, the project’s leadership included the senior physician director for resource stewardship, the manager of business operations for acute care services, and the director of clinical and business analytics reporting. In addition, senior-level medical directors of the physician group that serves KP Georgia provided support.
“The biggest barrier that we were concerned with was the buy-in of the physicians,” Pugel said, adding that project leaders also identified risks such as inconsistent guideline adoption, fear that patient satisfaction would drop, and actual decline of patient satisfaction, which clinicians are evaluated on.
“We thought we could get a good group of physicians to change. What we didn’t expect was such a dramatic change in some of their practices,” he said, attributing success to a change management approach that emphasized broad-based support from senior executive leaders, CME activities, integrating guidelines into the EHR system, handouts, posters and talking points for use with patients, and performance feedback to clinicians. Groups meetings, individual appointments and email updates were used to educate clinicians and staff about the initiative.
Rates of CBCs at a routine physical exam declined from an average 42.7 percent to 3.2 percent. The total number of CBCs and EKGs during all ambulatory visits each dropped by more than 50 percent. Rates of inappropriate bone scans decreased from an average of 25.4 percent to 2 percent, while Increased use of appropriate bone scans among women aged 50-65 did occur. Rates of imaging for uncomplicated headache decreased from an average 10.8 percent to 6.9 percent.
“Physicians get into habits, and some of them use preference lists in their EMR orders … not really thinking about what’s needed and what isn’t needed. A lot of patients now are very thankful we’re not providing unnecessary care.”