Choosing Wisely

From the Winter 2015 edition of Vanderbilt Medicine Magazine

The U.S. medical system spends $750 billion a year on health care that doesn’t result in improved health outcomes. In fact, one-third of medical spending is wasted on unnecessary procedures, according to a report from the Institute of Medicine.

Patients sometimes ask for tests and treatments that are not necessarily in their best interest. And physicians often struggle with decisions about ordering tests and procedures as a way of covering all possible bases.

Now there is a new campaign—Choosing Wisely—designed to help physicians, patients and other health care stakeholders think and talk about overuse of health care resources in the United States.

Choosing Wisely is a national initiative of the American Board of Internal Medicine (ABIM) focused on encouraging increased communication between health care providers and patients about overuse of laboratory tests and procedures.

What began as a friendly challenge prompted by the campaign is creating change at Vanderbilt University Medical Center.

Led by teams of Vanderbilt resident physicians, the initiative is reducing repetitive lab tests and making a visible impact on health care delivery.

Initially, the Choosing Wisely lab project involved eight resident groups in the Department of Medicine teaching services. It has expanded and is operational in the four general medicine non-teaching services, three surgical services (trauma, gastrointestinal/laproscopy and endocrinology/oncology) and two neurology services (general neurology and stroke).

“Although I didn’t have any expectations of how the program would take off, we are definitely in uncharted territory,” said Wade Iams, M.D., internal medicine resident and co-chair of the Choosing Wisely House Staff Steering Committee. “I have been pleasantly surprised with the residents’ and hospitalists’ change of behavior in buying into the initiative and understanding the goal, which is improving patient care and learning cost-effective principles.”

Since the implementation of the Choosing Wisely initiative at Vanderbilt in April 2014, the campaign has:

  • Saved $427,946 in medical charges
  • Avoided $4,011 in unnecessary labs
  • Prevented 20,057 ml of blood from being drawn

News of the success of the initiative has spread. The Choosing Wisely committee has been pulled in many different directions for expansion and collaboration.

One such area is telemetry, a continuous rhythm strip monitoring device. Led by hospitalist Elizabeth Rice, M.D., FHM, telemetry was one of 250 Choosing Wisely recommendations as well as an area of overutilization suggested by the Society of Hospital Medicine (SHM).graphIn addition to patient care, hospitalists are tasked with looking at ways to improve hospital efficiency or patient quality of care. Their target: patient flow. The culprit: inappropriate use of telemetry.

“Appropriate use of telemetry is an issue many hospitals are experiencing and it is affecting patient flow,” said Rice, director of clinical operations of hospital medicine and medical director of 8N, 8S and the clinical transition unit. “We have a sense that people are ordering telemetry because they are not confident of the true guidelines or recommendations for its use and once it is ordered, staff forget about it.

“Basically patients are waiting in the emergency department or in post-anesthesia care unit after surgery because telemetry has been ordered for them but there is no bed available.

“Our goal in this process is to get people to think more about the true guidelines for ordering telemetry and to think about the parameters to discontinue it. We want to improve the ability of patients to move to a bed and not sit waiting because the resource is not available.”

Rice said general indications for telemetry focus around heart issues, but it is often ordered for patients who don’t fit the true guidelines. She also noted that telemetry monitoring was exceeding the American College of Cardiology (ACC)-recommended 24-48 hour observation period.

Her team has begun educating various providers throughout the Medical Center about the updated guidelines, taking steps to place the discontinuation orders under the nursing protocol as well as initiating a change to WizOrder, Vanderbilt’s online computer order entry system.

“Education is the biggest piece of this project,” said Rice. “But another important part is getting the computer to prompt people to do the right thing. The order set needs to ask the right question.”

The Choosing Wisely team anticipates a move toward an automated electronic notification system that will provide physicians with data from their target service lines. Presently the team is compiling the data and emailing feedback to each physician group involved.

Although the telemetry project doesn’t fall directly under the Choosing Wisely program, the two initiatives work closely to create a “less is more” health care environment to provide safe and cost effective care to patients.

The national Choosing Wisely campaign was launched in 2012 with nine medical societies publishing 45 recommendations of tests, treatments and procedures that were deemed overused or wasteful.

John Held, director of communications for the ABIM Foundation, said the campaign has grown to more than 70 societies with more than 325 recommendations and additional members of the team including the American Dental Association, American Academy of Nursing and the American Physical Therapy Association.

“The goal of Choosing Wisely was to spark conversations about waste and overuse,” said Held. “There is a growing body of literature that seems to show progress is being made in this area.

“The work at Vanderbilt is a prime example of what we were hoping would come from Choosing Wisely,” he said. “There is still much work to be done to address waste and overuse and we’re hopeful the campaign is embraced and implemented in care settings across the country.”

Iams said that his group has fielded inquiries from other centers with sights on implementing similar campaigns at their institutions. Vanderbilt’s group also recently participated in a case study supported by the Association of American Medical Colleges (AAMC) as well as presented at AAMC meetings to help make future initiatives more efficient at other academic medical centers.

“We are really trying to talk to as many people as we can to help support the efforts and provide as much direction or input as possible,” said Iams. “Each institution approaches these initiatives in different ways so having any level of feedback seems to be helpful.

“At Vanderbilt, we want to create a rapid way for the initiative to stick in people’s minds. We don’t want to experience success in one area, and that’s it. We want to feed off the impact that Choosing Wisely labs have had and utilize what we have learned as we move on to the next area of overutilization.”