The statistics speak for themselves: More than 2,000 physicians have participated in 748 projects aimed at advancing evidence-based care at Sutter Health, a not-for-profit health system and partner in California’s Integrated Healthcare Association’s Choosing Wisley® grant. Data shows that these efforts have reached half a million patients and led to $8 million in savings — during the past 24 months alone.
During the past few years, Michael van Duren, MD, MBA, Vice President of Variation Reduction for Sutter Health, has worked with physicians to improve their practice patterns by educating them about Choosing Wisely society recommendations to avoid unnecessary care. Top-down and carrot-and-stick approaches have limited success, he said, as it’s better if physicians are self- or peer-motivated. He’s seen positive results by gathering doctors in peer groups and providing them with individual data about their behavior in a way that is respectful, helpful and actionable.
“We find that physicians want to see where they stand in relation to their peers,” he said. “This intervention gets them engaged. It is important to gauge their reactions, emotions and nonverbal cues and then encourage a respectful discussion.”
Dr. van Duren recognized this type of meeting could trigger defensiveness, resentment and disengagement if clinicians were seen as not performing at the same level as their peers. That is why he recommends going beyond simply presenting the data. He also provides more focused feedback on what physicians need to know to do something differently and improve the next day. To ensure that this is done respectfully, he said it is important to create a safe environment and to let the group initiate the discussion and determine a solution.
“There is no shortcut,” Dr. van Duren said. “It has to be an authentic face-to-face conversation. You can’t automate it. Physicians always want to do the right thing for patients and given a little helpful feedback, they will.”
After physicians see data about how their behavior might differ from their peers and from evidence-based recommendations, Dr. van Duren monitors and shares any variation reduction 12 months after the intervention as compared to 12 months prior. He usually sees a shift in ordering behaviors. As all physicians practice differently, the shifts can fluctuate from subtle to drastic.
In one example, Dr. van Duren presented data to a small Sutter family practice group that showed a four-fold difference—a common finding—in how physicians were screening for Vitamin D deficiency. This prompted the physicians to discuss how to better align with evidence-based practices, including Choosing Wisely recommendations. About 10 months later, data showed that they ordered 215 fewer tests.
After similar interventions involving Sutter clinicians, a group of urgent care doctors ordered 396 fewer CT scans for routine abdominal pain and a group of endocrinologists reduced inappropriate lab tests for hypothyroidism by 10 percent. Data has shown that sparking conversation among physicians about appropriate ordering has been successful in reducing unnecessary care, but Dr. van Duren said physicians’ reactions to variation reduction projects are just as important to consider.
“It is welcomed by physicians,” he said. “They have fun and want to look at more data.”