Overuse in health care continues to be a compelling topic of interest from a wide range of perspectives among scholars and researchers in 2019, with scores of articles published by many peer-review journals. Below are a handful of noteworthy articles related to the Choosing Wisely campaign for the first half of this year.
Annum Faisal, MD; Kayla Andres, MD; Jubran Afzal Khan Rind, MD; Aparna Das, MD; David Alter, MD; Jeevarathna Subramanian, MD; Tracy J Koehler, PhD; et al. BMJ Postgraduate Medical Journal, January 2019.
In this article, the authors examine an eight-week quality initiative aimed at reducing unnecessary blood tests that was implemented in three internal medicine resident inpatient services. The initiative included a 30-minute educational session, reminders prior to rotation and mid-rotation, and posters in work areas that displayed lab pricing and urged judicious testing. Residents were encouraged to justify the purpose of ordering tests in their daily progress notes. The evaluation criterion was an over 10 percent decrease between time periods. The study compared 293 patient records from the pre-intervention period with 419 in the post-intervention period. Median blood test count decreased from four to two tests per patient per day after the intervention. The study concluded that the frequency of unnecessary routine blood tests ordered in the hospital can be decreased by educating resident physicians, making them cost conscious and aware of the indications for ordering routine labs. Frequent reminders are needed to sustain the educational benefit.
Silas Trumbo, MD; Wade T. Iams, MD; Heather Limper, PhD, MPH; Kathryn Goggins, MPH; Jayme Gibson, ACNP; Lauren Oliver, ACNP, MSc; David L Leverenz, MD; Lauren R. Samuels, PhD; Donald W. Brady, MD, and Sunil Kripalani, MD, MSc. Journal of Hospital Medicine, February 2019.
In this article, the authors describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units at an academic medical center in the United States from October 2015 to June 2016, and evaluate de-implementation strategies. The prospective, nonrandomized study included the staff of a medical intensive care unit (MICU) and a cardiovascular intensive care unit CVICU), and utilized provider education, peer champions and weekly data feedback on CXR ordering rates. The authors found that the intervention made a modest but statistically significant reduction of CXRs ordering in the CVICU only, and that the factors supporting deimplementation included stable staffing, regular data feedback and engagement of peer champions. Barriers included for the lack of standard benchmarks for CXR ordering rates, poor intervention visibility and “waning investment among medical resident in the MICU due to frequent rotation and competing priorities.”
Sara D. Pasik, BA; Sophia Chiu, MS; Jeong Yang, BA; Catherine Sinfield, MPH; Nicole Zubizarreta, MPH; Rosemarie Ramkeesoon, FNP; Hyung J. Cho, MD4, and Mona Krouss, MD. Journal of Hospital Medicine, March 2019.
Hospitalized patients often have asymptomatic increases in blood pressure (BP), and national guidelines recommend treating with oral agents to slowly lower BP. But often clinicians resort to intravenous antihypertensive medication, which cause unpredictable changes in blood pressure. These researchers designed a quasi-experimental study to address inappropriate ordering of IV antihypertensive agents and subsequent adverse events among patients in two medical units from January 2016 to February 2018. The study used a multidisciplinary intervention, including clinical education, a treatment algorithm, audit and monthly feedback, and an electronic medical record change — with the key measures being total numbers of orders, inappropriate orders, adverse events and alternate causes per 1,000 patient days. The initiative resulted in a significant reduction in inappropriate use of IV antihypertensives and an associated decrease in adverse events.
John N. Mafi, MD, MPH; Patricia Godoy-Travieso, MSN, MHA, RN, and Eric Wei, MD. JAMA Internal Medicine, March 2019.
In this study at two academic safety-net medical centers in California, the researchers explored whether a multipronged quality improvement initiative could reduce low-value preoperative care for patients undergoing cataract surgery and thereby reduce costs in a large safety-net health system. Interventions included data feedback, clinician champions and clinical education. The initiative involved a combined 1,054 patients in the intervention and control groups, and took place from April 13, 2015 to April 12, 2016, with an additional 12 months to assess sustainability. For the intervention group significant decreases occurred in preoperative visits, chest x-rays, lab tests and electrocardiograms, compared with the control health system. During 12-month follow-up, preoperative visits increased in the intervention group, but the number of chest x-rays, laboratory tests, and electrocardiograms remained low. Also, three-year projections estimated a modest amount of cost savings but with losses for fee-for-service health systems, indicating a potential barrier to eliminating low-value care.
Laura Sue, MD, MPH; Julie Kim, MD; Hazel Oza, BS; Thomas Chong, MD; Hawkin Woo, MD, MPH; Eric Cheng, MD, MS, and Angela Leung, MD. Journal of the Endocrine Society, April 2019.
This study assessed the ordering practices among clinicians who manage patients with hypothyroidism at a large urban tertiary/quaternary care academic health system. A best practice advisory (BPA) alert was developed following the collection of baseline data and consisted of a pop-up window triggered when any type of T3 laboratory test was ordered among patients who have thyroid hormone (both generic and brand-name levothyroxine formulations) listed in the medical record. The BPA alert required user acknowledgment and a clinical decision-making process before the T3 laboratory test order could be placed. After the BPA alert was launched in September 2018, inappropriate T3 ordering was triggered a mean of 127.3 times in the initial three weeks, compared with 165.8 times pre-launch. The mean fell to 115.0 times in the next three-week time period. As a result of the BPA, providers canceled as many as 12.3 percent of triggered T3 orders during the six weeks after launch.
John G. Albertini, MD; Peiqi Wang, MD, MPH, and Christine Fahim, PhD, et al. JAMA Dermatology, May 2019.
This research team examined whether the use of a behavioral intervention such as nationally benchmarked peer-to-peer reporting could reduce the overuse in Mohs micrographic surgery, a skin cancer treatment that uses staged excisions based on margin status. The nonrandomized controlled intervention study included 2,329 U.S. surgeons who performed the MMS procedures over a 27-month period (from January 1, 2016 to March 31, 2018). The surgeons were identified using Medicare Part B claims, with the intervention group consisting of physicians affiliated with the American College of Mohs Surgery (ACMS) and the control group being non-ACMS affiliated physicians. Individualized performance reports were sent to all outlier surgeons in both groups as well as inlier surgeon in the intervention group. Post-notification, outliers demonstrated a decrease in mean stages per case compared with outlier in the control groups. The study estimated an $11.1 million reduction in Medicare spending based on decreases in both the intervention and control groups.