Nearly two years ago, Kaiser Permanente Georgia undertook efforts to promote high-quality care by ensuring conversations with patients about what procedures, tests and treatments are right for them were based on the latest science and evidence. When discussing what tools could help enhance these doctor-patient conversations, leaders at Kaiser Permanente consistently referenced those created by the Choosing Wisely® campaign.
“We felt that if we could leverage the campaign, our provider base would get involved in looking at variation around test ordering,” said Helen M. Ward, MD, FCCP, Pulmonary and Critical Care Medicine and Senior Physician Director for Resource Stewardship. “The campaign seemed like an ideal way to introduce the concept to physicians practicing together.”
As part of various initiatives to provide evidence-based care, the Department of Resource Stewardship examined data about its physicians’ practice patterns and shared findings with medical leadership teams. The Adult Medicine department leaders decided to take a closer look at ordering patterns for complete blood count (CBC) screening tests and four procedures from specialty society Choosing Wisely recommendations:
- Don’t perform neuroimaging studies in patients with stable headaches that meet criteria for migraine. (American Headache Society)
- Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms. (American Academy of Family Physicians)
- Don’t use DEXA screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors. (American Academy of Family Physicians)
- Don’t do imaging for low back pain within the first six weeks, unless red flags are present. (American Academy of Family Physicians)
Adult Medicine physicians learned about Choosing Wisely and practice variation through department-wide presentations, emails, and a toolbox of resources that included links to specific campaign recommendations within Kaiser Permanente’s electronic medical records (EMR) system.
Resource Stewardship also used the EMR to develop automated reports to show ordering patterns that did not reflect evidence-based recommendations for the selected tests and procedures. Leadership meetings allowed the team to discuss measures, view reports and address questions and concerns with the chief and lead physicians.
“If you are going to provide information to people about how they are performing, you have to get it right,” Dr. Ward said. “We wanted doctors to feel confident with the measurements so they would invest in the outcomes. We went through multiple iterations and steps before we all felt comfortable.”
Adult Medicine physicians received monthly reports about their ordering behavior, which allowed those in the department to compare stats. Baseline measurements showed a pattern of unwarranted test ordering, and, since physicians trusted the reports, they began to address this variation.
“We had a tremendous response,” Dr. Ward said. “Providers embraced it in a variety of ways. They used this information to share relevant research, hold lunchtime discussions and launch unit-based projects to make sure they were sticking to recommendations.”
The first measurements after the intervention showed more appropriate ordering, which led to a 76 percent decrease in CBC testing and other areas measured:
- 35 percent in imaging for headache
- 61 percent in annual EKGs for low-risk patients
- 76 percent in DEXA ordering for the specified population
- 53 percent in low back imaging
In addition to the reports, Kaiser Permanente Georgia used patient-friendly materials, including Choosing Wisely exam room posters, handouts and newsletter articles, as conversation starters.
“By leveraging the Choosing Wisely campaign to initiate discussions with patients about appropriate, evidence-based care we have ensured our providers are consistently delivering high-quality care,” Dr. Ward said.