Fletcher Allen Takes Grassroots Approach to Choosing Wisely

Vermont’s Fletcher Allen Health Care is engaged in a continuous effort to reduce the misuse or overuse of tests and treatments its clinicians provide.

Inspired by the American College of Physicians’ High Value Care initiative and the Choosing Wisely® campaign, Fletcher Allen’s Department of Medicine launched an ongoing “Choosing Wisely” project in 2012, soliciting suggestions from faculty about tests and treatments that should be performed less frequently. Virginia Hood, MD, a nephrologist and professor at the University of Vermont College of Medicine, leads the effort, tapping in to her experience as the President of the American College of Physicians when it launched its High Value Care initiative to promote appropriate care and reduce overuse.

More than 20 suggestions were submitted within the program’s first week, and faculty members continue to suggest interventions using a simple form created by project leaders.

“Our approach has been a grass-roots approach: asking physicians what they want to do instead of telling them what they shouldn’t be doing,” said Dr. Hood.

The enterprise involves a team approach with input from the Jeffords Institute for Quality, laboratory, IT and other departments.

According to Dr. Hood, projects are selected based on a number of standards, with ideal candidates meeting the following criteria:

• an evidence-based guideline or consensus recommendation is available for the test or treatment that is considered overused;
• there is a reliable measure, preferably available electronically;
• the proposed outcome would be meaningful, producing significant reductions in harm, cost and/or patient inconvenience;
• the project would not substantially increase physician workload;
• there is a physician champion;
• an educational component for trainees is included; and,
• the work involves more than one group or division.

“Initially we’ve tried to do fairly noncontroversial things,” Dr. Hood said. “We want the process to be accepted, and we don’t want to interfere with physicians’ ability to individualize decisions when it’s necessary. We also don’t want to do things that are going to cause a lot more work, because everyone is overwhelmed.”

The interventions included both technical and IT fixes such as reformulating electronic order sets and redesigning ordering forms to include evidence-based indications and educational efforts for physicians and trainees. Eight projects are ongoing or have been completed thus far; highlights have included:

• Reducing the number of tests for kidney function in patients whose kidneys have failed and who require permanent dialysis, and are then admitted to the hospital for another reason: The effort began with education for residents and also included changes to the electronic medical record to provide decision support. Over a six-month period, the number of unnecessary tests was reduced from more than 1,300 per 1,000 patient days to fewer than 200 per 1,000 days with a goal of further reduction.
• Limiting the number of DEXA scans performed to measure bone density without evidence-based indications: Paper and electronic ordering forms were revised to include the clinical evidence about the appropriateness of DEXA scans, which the American Academy of Family Physicians has suggested are used too frequently. According to Dr. Hood, initial success was limited, and then the ordering forms were further changed with physician input to make them clearer and more informative. Over the course of the eight-month initiative, the frequency of non-indicated scans decreased from more than 10 percent to less than 1 percent.
• Reducing the use of chest X-rays in the ICU: Before Fletcher Allen’s “Choosing Wisely” intervention, most intensive care unit patients were receiving daily chest X-rays. Working together, medical and surgical ICU teams developed strict criteria for when a chest X-ray was necessary for decision-making about patient care. The adoption of these criteria reduced the utilization of chest X-rays in the ICU by almost half within a few months, in keeping with the Choosing Wisely recommendation from the Critical Care Societies Collaborative against daily diagnostic tests.

Dr. Hood said that as the initiative has continued, Fletcher Allen has honed its expectations for each intervention – they look for six-month interventions, and then seek to sustain progress, revisiting the data after a few months to ensure that utilization has not reverted to the previous patterns. Ideally, she said, they operate four interventions simultaneously throughout the year.

Fletcher Allen is also seeking to share information about the project with the public through its website, and is exploring the possibility of expanding the program to include other health systems in Vermont. “We want to share what we are doing, and to learn from others’ efforts,” Dr. Hood said.