Coming Face-to-Face with Unneeded Tests
When Yale’s Department of Emergency Medicine embarked on an overuse reduction program, it employed academic detailing—in which clinicians engage in face-to-face education with their peers about the value of particular tests and treatments—to reduce the number of unnecessary blood coagulation studies performed at Yale’s three emergency departments. Arjun Venkatesh, MD and chief resident Jessica Walrath, MD, who led the project, sent five residents to pharmaceutical sales meetings to learn how drug representatives market their products to clinicians then they helped the residents apply what they learned to determine how best to use the detailing model to reduce unnecessary studies. Their resulting strategy included both face-to-face meetings with emergency physicians and a “leave behind” of cafeteria vouchers, and educational materials (e.g., screen savers and postings on message boards) in nursing break rooms. After one month of the intervention, unnecessary studies ordered for patients with chest pain declined from 55 to 30 percent, and orders for patients as a whole declined from 12 to 8 percent.
This intervention followed earlier efforts to reduce “point-of-care” blood testing and orders for urine cultures. Topics were selected based on a survey of emergency department physicians, advanced practice clinicians, and nurses about their priorities for reducing overuse. (Survey results were published in the American Journal of Emergency Medicine.)
The first effort sought to encourage clinicians to abandon the frequent practice of ordering both point-of-care blood testing—which delivers quick results on a more limited range of conditions—and a full blood chemistry work-up, which is slower but more comprehensive. Through a “Choose Your Chemistry Wisely” effort that included working with nurses on scripting and physicians on ordering, duplicate orders declined from 230 to about 100 per week.
The second effort addressed a similar problem: due to time constraints, clinicians were ordering screening urinalysis and urine cultures simultaneously, even though the culture would be appropriate only if the screening was positive. This led not only to unnecessary screening but also to downstream effects, as patients received inappropriate antibiotics prescriptions because of false positives in the cultures. Project leaders worked with colleagues in lab medicine and infectious disease to create a new process, in which the lab would perform a culture only if the screening result was positive. This led to an annualized reduction of approximately 10,000 urine cultures.
