Reducing Overuse Through ‘Bite Size’ Projects

May 21, 2020

Choosing Wisely is at the heart of California’s St. Jude Medical Center’s effort to deliver appropriate care.

“Choosing Wisely serves as the foundational underpinning for all of our discussions with clinicians regarding how we can deliver the highest value care to our patients,” said Alistair Aaronson, MD, MHA, FACP, who joined St. Jude (part of Providence St. Joseph Health System) in 2017 as its Executive Medical Director for Operations and High-Value Care.

Under Dr. Aaronson’s leadership, the 320-bed hospital launched a series of “bite-size projects” to reduce overutilization. Clinicians would pick a topic where there was anecdotal evidence of utilization and then select a Choosing Wisely recommendation related to that topic. They would then compare their practice patterns against the recommendation; if the results were not positive, they would develop a project to address the overuse.

One early effort was a nurse-driven protocol to reduce telemetry, which achieved a utilization reduction of 25-30 percent. Bedside nurses screened patients who were on telemetry to see if they met the criteria put forth by the American College of Cardiology and American Hospital Association for telemetry use. When a patient did not meet the criteria, nurses would contact the ordering physicians and ask them to discontinue telemetry. Dr. Aaronson personally addressed physician concerns about discontinuing. St. Jude monitored patients who were removed to determine if any (a) needed rapid response team assessments within 12 hours, or (b) were returned to telemetry within 24 hours; no patients met either criterion.

The system then turned to imaging, beginning with the use of CT scans for patients presenting with syncope. “Imaging was a hot topic that no one knew how to address,” Dr. Aaronson said. St. Jude held educational sessions with emergency department clinicians, reviewing the Choosing Wisely recommendation from the American College of Emergency Physicians against CT of the head for asymptomatic adult patients presenting with syncope, insignificant trauma and a normal neurological evaluation. St. Jude also encouraged radiologists to cite Choosing Wisely as a reason to have peer-to-peer phone conversations with emergency physicians who ordered CT scans for patients with simple syncope.

“Due to the evidence-based nature of the Choosing Wisely recommendation, buy-in was fairly easy, and the emergency physicians quickly rallied around curbing CT head orders in that patient population,” Dr. Aaronson said.

The project resulted in a 57 percent decrease in head CT orders over an eight-month period. Dr. Aaronson said it also led to improved patient throughput in the ED, significant cost savings for patients, and a reduction in harmful radiation exposure.

St. Jude then sought to reduce its use of CT scans to diagnose pulmonary embolism in low-risk individuals. Here, too, the focus was on emergency physicians and radiologists, the latter of whom were encouraged to run their own Wells’ criteria and push back on unjustified orders. Although Dr. Aaronson said that emergency physicians expressed concerns about missing a diagnosis, utilization declined by about 10 percent in the initial 2-month stage of this ongoing project.

Reducing unnecessary imaging for low back pain is also a priority for St. Jude, which is educating its clinicians about appropriateness criteria and collecting baseline data on utilization.

“The most challenging part in this work is coming to consensus about what the evidence really points toward,” Dr. Aaronson said. “Individuals will have their own biases and cite evidence to support them. We aren’t using Choosing Wisely as gospel or dogma; we are trying to get consensus. Physicians are motivated to do what is in their patients’ best interest.”

Dr. Aaronson said that systems should never consider the work of avoiding unnecessary care to be finished. “It’s a constant process of keeping a culture alive based on constant reinforcement,” he said. “You should always seek to be higher value than you presently are.”

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