Sticking to the Script
As one of the partner provider organizations of Choosing Wisely grantee Washington Health Alliance (WHA), Group Health Cooperative has developed the “Change Three Things” initiative to address:
- the overuse of antibiotics for upper respiratory viral infections;
- imaging for uncomplicated headaches; and
- too frequent Pap tests for women between the ages of 30 and 65.
Group Health, a consumer-governed, nonprofit health system in Washington State and North Idaho that serves about 625,000 members, is currently focusing on reducing unnecessary antibiotics for upper respiratory viral infections. Two clinician champions – Angie Sparks, MD a family physician and Debbie Brown, a clinical nurse manager – are leading these efforts.
Late last year, Group Health hosted an “improvement event” that involved clinicians and staff from across the health system’s medical centers to rapidly design and test key tools to reduce antibiotic prescribing. During a one-day in-person meeting, they convened a team that included representatives from primary care, urgent care and a walk-in clinic. One of their focuses was to create scripts for clinician-patient conversations about why antibiotics might not be needed.
“It was important that people from across the team were represented,” said Dr. Sparks. “We wanted the urgent care perspective, since we find that a lot of antibiotic prescribing happens in those settings. We wanted to include a representative from the appointing team, who schedules patient appointments, and the consulting nurse department that helps take patient calls, as these staff members can help patients understand that they might not need antibiotics from the very beginning.”
All scripts were based on The Four Habits Model — a standard framework to guide clinician/patient communication. They were all similar — for consistency across the system and to reduce mixed messages from different clinicians.
“Empathy is important,” said Dr. Sparks. “If a patient feels like the doctor is really trying to understand how they feel, he or she will be more likely to understand why they aren’t receiving the antibiotics they might have been expecting to ease their symptoms. It’s about understanding where your patient is at and what they expect and helping them make a decision that is right for them.”
For example, the scripts recommend how clinicians can help patients with their symptoms with language such as: “I’d like to help you manage your symptoms while you wait for this virus to run its course, what symptom is impacting you the most right now (cough, congestion, aches, etc)?”
To support the scripts, the team identified Choosing Wisely materials to include in the electronic medical record (EMR) so clinicians can access standard after-visit print-outs to give patients to help them learn about at-home treatment as alternatives to antibiotics, how long symptoms might last and what to do if their symptoms persist.
In the days following the in-person meeting, the scripts and tools were put into practice and the team had follow-up phone calls to fine-tune these items. The teams also collected data and found that a third of the patients really wanted antibiotics with the belief that it helped them in the past. About half of those patients were satisfied with the explanation that antibiotics would not benefit them and the recommendation for home treatment – but they wanted to hear it from a physician.
And recently, Group Health has started sending monthly reports to clinic leaders and physicians with data about antibiotic prescribing for upper respiratory viral infections. The expectation is that they will, in turn, share the reports with their teams and encourage conversations about what works and continued use of the scripting and tools.
“Since we started this work we have had an overall 25 percent reduction in antibiotic prescribing for upper respiratory viral infections,” Dr. Sparks said. “We could have implemented the project without the reporting element but we felt it was more effective with the data to see how you are doing in comparison to your peers.”