The U.S. Department of Veterans Affairs’ Quality Enhancement Research Initiative (QUERI) is furthering its mission to improve patient care by funding projects to study de-implementation of ineffective diagnostic and therapeutic care.
David Au, MD, Director of the Center of Innovation for Veteran-Centered and Value-Driven Care at the VA Puget Sound Health Care System, said the Choosing Wisely® campaign helped establish a framework for thinking about low-value care, which has informed three different projects across the Bedford VA in Massachusetts and Puget Sound VA systems. These projects will engage hundreds of patients and clinicians for about three years beginning this spring.
Organization partners have been a critical component to building the projects, Dr. Au said. The National Center for Health Promotion and Disease Prevention is launching one project that targets de-implementation of repeating CT scans too frequently after detection of small lung nodules, which is common in lung cancer screenings. As per the American College of Chest Physicians and American Thoracic Society’s Choosing Wisely recommendation, low-dose chest CT screening for lung cancer might be valuable for high-risk patients, but screening also has the potential to cause adverse effects.
“We are trying to standardize radiologist interpretation with guidelines and de-implement excessive repeat CT scanning to minimize harm,” he said.
At the Bedford VA, Adam Rose, MD is leading a team working to launch another project with the VA’s Pharmacy Benefit Management program to reduce the use of antipsychotic medication for sedation of older patients with dementia. The American Geriatrics Society’s Choosing Wisely recommendation notes that antipsychotic medicines are often prescribed for patients with dementia, but they provide limited and inconsistent benefits and pose risks.
Rose’s team plans to use an audit and feedback system to monitor the usage of these medications and provide information to clinicians in order to assess and adjust how successful the treatment is for their patients.
The third project topic—one that did not come directly from a Choosing Wisely recommendation but was inspired by concepts of the campaign—focuses on a coordinated effort between the Office of Specialty Care Services and pulmonary leaders at the Puget Sound VA to reduce overuse of inhaled corticosteroids for patients with COPD.
Dr. Au said that inhaled medications are often perceived as safe and inexpensive, but this is not always the case. Patients ask for them and physicians don’t want to stop medications that patients might view as being helpful.
“It is important to look at it as an inappropriate medication that is being delivered and people are being treated who don’t have a disease,” he said.
Dr. Au and his team will review medical records to identify patients using inhaled corticosteroids but who do not have a clinical indication for these medications. From there, they will use an electronic consult to communicate with a patient’s primary care physician prior to a patient visit in order to provide rationale about why the patient might not need an inhaled corticosteroid and, if the primary care provider agrees with the recommendation, complete discontinuation orders to stop the medication.
Since the consult arrives around when the visit starts, it can prompt the doctor-patient conversations. And, unlike EHR alerts, this colleague-to-colleague communication uses the EHR as the medium to proactively reduce unneeded care.
“These quality improvement projects will be a learning process,” Dr. Au said. “I think that focusing on process measures can actually change culture, and changing culture leads to many more meaningful changes.”