In 2011, the quality and safety team at Harvard Vanguard Medical Associates, a multispecialty medical group practice in eastern Massachusetts, worked to develop colonoscopy frequency guidelines mirroring the national recommendation of once every 10 years for average-risk patients. Their efforts coincided with research conducted by Thomas Sequist, MD, former Director of Research and Clinical Program Evaluation at Harvard Vanguard, which ultimately showed that colonoscopies were being prescribed three to five years too early among average-risk patients.
Armed with these findings as well as the American Gastroenterological Association’s (AGA) Choosing Wisely® recommendation around colonoscopy frequency, Harvard Vanguard convened doctors and clinical leaders to discuss whether more frequent colonoscopies were really beneficial.
Richard Lopez, MD, Chief Medical Officer at Atrius Health, a nonprofit alliance that includes Harvard Vanguard, said specialists had concerns about certain types of polyps being easily missed during colonoscopies. To address these concerns, Harvard Vanguard invited a national expert on colorectal cancer screening to present scientific evidence to physicians and answer their questions.
Dr. Lopez said that specialists know their area of expertise in detail, but sometimes they base what they prescribe on anecdotal or routine experience.
“Part of the work is to sort out what the literature said as opposed to their experience,” he added. “We want to bring the conversation back to evidence-based medicine. With a lot of education and discussion, we were able to work through those concerns.”
At the conclusion of the process, Harvard Vanguard reached agreement on the 10-year interval for average-risk patients. To ensure these guidelines were followed, reminders were embedded into electronic medical records (EMRs) so doctors would know when patients were due for colonoscopies, and when they weren’t.
“Patients are not generally enthusiastic about colonoscopies, so the news that they are not due yet is usually well-received,” Dr. Lopez said. “If there are questions, patients usually are accepting of the rationale about the guidelines, and it is likely reassuring to them that the practitioner is following evidence-based guidelines and are up-to-date.”
A baseline audit was conducted to gauge if doctors were adhering to the colonoscopy screening guideline and continued conversations around variations in practice.
“We present the data and ask why we see the variation,” said Thomas Isaac, MD, Medical Director, Clinical Variation and Quality Standards at Harvard Vanguard. “There are many reasons for variation. Practice styles are very different. Non-judgmental conversations are an important way to bring people together to understand what’s happening. The Choosing Wisely recommendation also provided more emphasis on the 10-year interval.”
Follow-up audits showed that behavior was changing and aligning with the Atrius internal guidelines as well as Choosing Wisely recommendations.
Dr. Isaac said Harvard Vanguard’s clinical variation department has started to assess and prioritize other Choosing Wisely recommendations, including those related to back pain, to help establish appropriate use of care.