A new, periodic series in Updates from the Field, “Research Roundup,” highlights recently published research related to Choosing Wisely®. (Note: Some articles require subscription.)
Checklists, Radiation Exposure Information and Strategies for Better Point-of-Care Conversations
“Facilitating Evidence-Based Clinical Decision Making” (Online, February 2016)
Mathematica Policy Research, with support from the Robert Wood Johnson Foundation, recently explored ways in which payers, delivery systems, health insurers and other purchasers can support providers and patients with evidence-based decision-making in typical point-of-care situations. Through a literature review, Mathematica identified factors that influence physicians’ and patients’ decision-making at the point of care. These factors shaped interviews and meetings to explore both barriers to, and facilitators of, evidence-based medical care. Conversations with physicians, health care consumers, clinician leaders, payers, purchasers and other stakeholders were framed around four representative clinical cases often faced by physicians and patients, all of which have clear evidence from Choosing Wisely recommendations on how to proceed.
In February, Mathematica released two reports about its findings from these conversations. Researchers concluded that promising strategies include local payers and community organizations providing resources and preferential payments so physicians and patients can share decision-making, and engage in conversations to facilitate evidence-based care.
“Multifaceted Intervention Including Education, Rounding Checklist Implementation, Cost Feedback, and Financial Incentives Reduces Inpatient Laboratory Costs” (Journal of Hospital Medicine, February 2016)
Inspired to reduce waste by the Choosing Wisely campaign, The University of Utah general internal medicine hospitalist service identified laboratory testing as an area for improvement and implemented a multi-pronged initiative to reduce unneeded tests. The initiative included:
- education of all providers involved;
- standardization of the rounding process, including a checklist review, with the expectation that all plans for lab testing be discussed during rounds;
- monthly feedback at the hospitalist group meeting regarding laboratory costs, including making individual performance viewable; and,
- a financial incentive. (Fifty percent of cost savings realized by the hospital will be shared with the Division of General Internal Medicine to support future quality improvement projects.)
Through this intervention, the number of tests per day significantly decreased for all tests, the lab cost per patient day was reduced from $138 to $123, and readmission rates declined from 14 to 11 percent. These reductions were not achieved in a control group that was part of the study. The authors report that the hospitalists believed “the driving factors for change were those related to process change, specifically, the use of a standardized rounding checklist to discuss lab testing and the routine review of lab costs at group meetings.”
“Developing a High Value Care Programme from the Bottom Up: A Programme of Faculty-Resident Improvement Projects Targeting Harmful or Unnecessary Care” (BMJ Quality and Safety, December 2015)
This paper describes an organized program to combat overuse at the University of Vermont Medical Center. The chair of the Department of Medicine asked faculty to submit ideas for high-value care projects, using Choosing Wisely recommendations as examples. One project led to a 90 percent reduction in DEXA screening on women 65 and older without clinical risk factors for osteoporosis.
“Displaying Radiation Exposure and Cost Information at Order Entry for Outpatient Diagnostic Imaging: A Strategy to Inform Clinician Ordering” (BMJ Quality and Safety, January 2016)
Researchers found that displaying both radiation exposure information for CT scans and cost information for CT, MRI and ultrasound on an electronic referral system for outpatient ordering, influenced clinician behavior at an urban safety net health system. The ratio of CTs to ultrasounds declined by 15 percent, and the ratio of MRIs to ultrasounds declined by 13 percent. More than 80 percent of clinicians said they noticed the radiation exposure information and the cost information, and reported that the radiation exposure information was more influential than cost information in determining which imaging study to order.