This is the second in a series of blog posts by Virginia L. Hood, MD, MPH, about the Choosing Wisely program at the University of Vermont Medical Center and the Larner College of Medicine at UVM. To read the first article in the series, please click here.
Vermont has often taken a grass roots approach to problem solving and here too we follow that tradition. Case in point: When Polly Parsons, MD, chair of the Department of Medicine at the University of Vermont Medical Center, decided we should undertake a “Choosing Wisely” (CW) project, she asked faculty for suggestions (CW is a partnership of more than 80 medical societies and consumer groups in the US that are providing information to physicians and patients about diagnostic tests of questionable value). Within a week more than 20 ideas surfaced.
With many to choose from, we developed a process that looked for projects that were of sufficient size to have an impact on reducing harm, cost or patient inconvenience, that did not increase work load, involved faculty mentors and trainees, and could be sustained through system changes after the initial project was completed.
Bringing about change requires a team approach. Our team includes staff from the Jeffords Institute for Quality, who provide background and follow-up measurements, EHR/PRISM operatives, laboratory personnel, nursing staff, and at least one faculty member and one resident or fellow for each project
Solutions included reformulating electronic order sets, redesigning ordering forms to include evidence-based indications, and educating physicians and trainees. Order sets, like check lists, help to standardize and streamline charting processes, allow safety measures to be incorporated into care and eliminate errors of omission. However, they can lead to extra tests being done that are not always needed. To counteract this tendency, we are striving to work with those who can tackle the challenges of the internal complexity of electronic health systems to make them part of the solution.
Here are some of the projects we have undertaken.
- Our first effort was to reduce the number of tests of kidney function in those persons whose kidneys have failed, require permanent dialysis and are admitted to the hospital for another reason. After many months we reduced the tests from more than 1,300/1,000 patient days to less than 200 and hope to reach zero..
- Another project involved avoiding screening colonoscopy for those over the age of 75 who had no risk factors for colon cancer. It turned out that few persons meeting these criteria had had a colonoscopy during the baseline period, although among those that had, there had been a rare complication. Patient and physician education is addressing this issue.
- We thought the way to limit people, without evidence based indications, from having DXA scans for bone density measurements, would be to help providers who order the test by making the paper and electronic ordering form simpler, clearer and more informative. After 2 or 3 iterations, this approach has reduced non indicated scans from > 10 percent to < 1 percent.
- Two interesting hospital projects have engaged members of more than one clinical department. In the intensive care units, most patients were receiving daily chest X-rays. When the medical and surgical ICU teams developed strict criteria for when a chest X-ray was necessary for decision making about patient care, changing the culture of ordering from “routine” to “by indication only” reduced the non-needed by almost half. Not only did this reduce potential harm to patients but saved radiology and nursing personnel time and cost to the system. A similar approach is providing clearer criteria for using new more sophisticated radiological technologies such as PET scans to aid management of women with breast cancer. By more careful documentation and following currently accepted national consensus guidelines, reduced rates of non- indicated testing could reduce inconvenience for patients and allow potential cost savings of >$200,000.00
No patient has been denied any needed tests. All decisions were made in consultation with the health care professionals working with the patients and although both the patients and the system will reap the benefit of lowering costs, the main goal is to reduce harm. Harm comes from the tests themselves, false positive findings with the consequent need for follow up tests, and concern on the part of patients about findings that turn out to be false or irrelevant.
From these initial projects we have learned many lessons that will help with each new one we take on. Systems are more complicated than they appear on the surface and require collaboration, better connections, and many players to bring about change. We still have limited evidence about when and when not to do certain tests so we must wait for new evidence to surface or develop it ourselves. However, one of the benefits of being in an academic center is that quality improvement projects are constantly underway and faculty are always reevaluating current knowledge in their own fields and sharing it within and outside the institution. Most importantly, we are continually reminded that a change in culture is needed to promote a “less is more” philosophy among both patients and professionals.
Virginia L. Hood, MD, MPH, is a nephrologist at the University of Vermont Medical Center and a professor at the Larner College of Medicine at UVM.