Choosing Wisely grantee partners Froedtert & the Medical College of Wisconsin (F&MCW) and Monroe Clinic have reduced the use of antibiotics for adults with bronchitis by more than 50 percent, in-patient blood transfusions by 43 percent and imaging for headaches and low back pain by 70 percent and 36 percent, respectively.
According to Gregory Blommel, MD, Medical Director of Quality and Outcomes at F&MCW, the determining factor in their success came down to one single moment in time: when the clinician places the order.
All efforts to promote evidence-based care through the Choosing Wisely campaign and change ordering behaviors hang on that brief decision-making moment. While a combination of interventions to engage patients, make data transparent and enhance workflow contribute significantly to the effort to reduce unnecessary care, Dr. Blommel said clinicians are ultimately responsible. Effective interventions start with analyzing the opportunities and barriers affecting the decision to place orders that can result in overuse.
“You have to deal with competing priorities, including patient satisfaction and time constraints, as well as clinician knowledge and prevailing norms and attitudes,” Dr. Blommel said.
While there may not be a one-size-fits-all approach for physician education and engagement, Dr. Blommel said small-group continuing medical education (CME) discussions led by peers that feature real-world cases and provider-level performance data is a successful first step. When accompanied by patient education, decision aids in the electronic medical records (EMR), performance data and leadership engagement, there are incremental gains.
“In the case of antibiotic prescribing, patient expectations vary by clinic, and managing those expectations need to be addressed locally,” said Dr Blommel.
Clinicians at F&MCW engaged front-line triage staff to create greater awareness among their patients about when antibiotics may not be needed. However, up to 50 percent of clinicians reported receiving a negative comment on patient satisfaction surveys based on not prescribing antibiotics and requested that doing the right thing should not count against them. Some physicians involved in the projects also earned points toward maintaining their board certification. Those in the Maintenance of Certification (MOC) group participated in two additional quality improvement cycles and had an increased improvement rate (about 50 percent) compared to their peers.
“We think the MOC improvement framework engaged clinicians, encouraged group problem-solving and led to a sense of ownership in terms of the outcomes,” Dr. Blommel said.
Other key findings from their work include:
- A “hard stop” in the EMR that included a clinical reminder and evidence for why imaging for low-back pain is not always helpful was effective. (Dr. Blommel stressed, however, that hard stops should not be overused.)
- Using nationally endorsed measures and engaging a team to collect, analyze and report data was an essential starting point, but measures need to be modified to provide individual clinicians their data.
“When you start out, you have to remember that the objective is to optimize the ordering patterns of the clinicians and to understand the dynamics of that discrete decision,” Dr. Blommel said. “There is no going back and closing a gap later. Clinician education and engagement is a necessary component but needs to be enhanced with data, patient engagement strategies and broad support of the organization including judicious use of decision aides in the EMR.”