Pathway to Evidence-Based Care
The University of Pittsburgh Medical Center (UPMC) assesses areas of low- or no-value care as part of its process to deliver quality care.
“We look to identify where we can improve by relying on available evidence and studying guidelines and recommendations, including those of the Choosing Wisely® campaign,” said Oscar C. Marroquin, MD, Vice President of Clinical Analytics for UPMC’s Health Services Division.
To standardize care and inspire clinicians to capitalize on opportunities to reduce overuse, UPMC uses clinical pathways, or care plans, that map patient journeys for certain conditions.
Dr. Marroquin said several UPMC departments use analytics to study variation in care, which informs where pathways can help physicians deliver high-value care. Committees of physicians and subject matter experts then collaborate to review literature and recommendations from societies to achieve consensus and create a pathway.
“UPMC has about 70 pathways, some of which include Choosing Wisely recommendations,” Dr. Marroquin said. “We have some that span the whole continuum of care and some that are more focused on specific procedures.”
When the pathway is established, physicians who will be involved in diagnosing and treating the condition are educated about the evidence, and information is then built into electronic health records (EHRs). The process involves developing the content, integrating it into the workflow and building alerts in the EHR to remind physicians of pertinent recommendations.
For example, the low back pain pathway is triggered when a patient sees his or her doctor for back pain. UPMC integrated relevant Choosing Wisely recommendations into questions clinicians ask patients to determine if there are any red flags and to decide the best course of action.
“We know that imaging is not recommended for uncomplicated low back pain, so we built an EHR alert that appears when patients present with these symptoms to prompt the doctor to talk with the patient about trying exercise and physical therapy instead,” Dr. Marroquin said.
The committees develop outcome metrics when the pathways are created to help track progress toward achieving goals. When they are being utilized, UPMC can track adherence and measure health care delivery and report on clinician behavior.
“We shared the results with clinicians, comparing baseline data before the pathway was started and from one year after it was implemented, since it is easier to identify trends over a longer term reporting period,” Dr. Marroquin said. “We knew that by incorporating the Choosing Wisely recommendations into the low back pain pathway, we would likely see an impact on imaging tests ordered.”
And UPMC did. Data from 2012 to 2014 showed a more than 50 percent decrease in X-rays, CT scans and MRIs ordered.
“It was exciting to see the tests that were not necessarily evidence-based happening less frequently,” Dr. Marroquin said. “We think that the pathways have contributed to awareness about unneeded care, but we can’t say that all the observed changes are only due to these implementations.”
In addition to sharing evidence and providing rich data, UPMC pathways are also designed to encourage physician–patient conversations about appropriate care to avoid waste–furthering Choosing Wisely’s mission. Multidisciplinary teams of physicians, nurses, rehabilitation workers and patient educators often discuss shared decision-making opportunities when developing pathways.
“We wanted to not only guide physicians, but to use shared decision-making tools to show patients why the physicians might be recommending or not recommending certain tests and procedures,” Dr. Marroquin said.
