University of Vermont

College of Medicine

Office of Medical Communications

Choosing Wisely: Department of Medicine Implements High Value Care Initiative

The Choosing Wisely initiative, spearheaded by Pam Stevens, R.N., Allen Mead, and Virginia Hood, M.B.B.S., M.P.H., is slated to continue with a second round of projects.
The Choosing Wisely initiative, spearheaded by Pam Stevens, R.N., Allen Mead, and Virginia Hood, M.B.B.S., M.P.H., is slated to continue with a second round of projects. (Photo by Raj Chawla)

Hospitals and academic medical centers across the country are working hard to cut costs while maintaining or improving the quality of care patients receive. A project in the Department of Medicine is at the leading edge of this effort: The goal of the DOM Choosing Wisely initiative is to create a culture among physicians, trainees and patients that reduces the overuse and misuse of diagnostic tests and procedures.

The department’s campaign draws from several national initiatives focused on cutting cost and improving value. Virginia Hood, MBBS, MPH, MACP, was tapped by Department of Medicine Chair Polly Parsons, M.D., to lead the department’s work after Hood’s recent service as president of the American College of Physicians, the largest medical specialty organization in the country. In 2011, the ACP launched the High Value Care Initiative, which provided clinical recommendations to help physicians deliver evidence-based care. The organization also partnered with Consumer Reports to educate patients about the benefits and potential harm resulting from common tests and procedures. In 2012, the American Board of Internal Medicine Foundation introduced the Choosing Wisely campaign, a model used by the Department of Medicine and dozens of medical societies and consumer organizations.

The problem is huge: The IOM estimates that about 30 percent of health care costs, more than $750 billion annually, are spent on wasted care. Hood says that education – for patients and physicians – is key to change. As guidelines are updated, and data on certain tests and procedures are gathered, physicians may not always be aware of all of the changes.

“Physicians really do want to do the right thing,” she says. “You get the best results when you collect the data and tell people what is happening.”

The DOM Choosing Wisely committee includes Hood, Allen Mead, the department’s director, and Pam Stevens, R.N., a quality improvement specialist at the Jeffords Institute. Former resident Justin Stinnett-Donnelly, M.D., M.S., played a key role in the pilot year as well. To start, the committee canvassed department faculty and chose four measures to focus on out of dozens identified by the group. The goal was to “shine a light” on the data, Mead says, and to pinpoint ways patient care could be improved by eliminating ineffective tests and procedures.

“Provide the right data and the physicians will take of the rest,” he says. “The goal is to create a process that allows for the best patient care.”

Four faculty members served as champions for implementing each of the initial projects. Hood led a project in the Division of Nephrology focused on a certain blood test- for creatinine - in patients with end stage renal disease. Although often submitted as part of a battery of blood work, it adds no value for the patient. James Vecchio, M.D., Division of Gastroenterology Chief, tracked colonoscopy screenings in patients over 75, and in patients who had a cardiac stent placed within the past six months. Meeting age standards for bone density screenings was a proejct led by Professor of Medicine Edward Leib, M.D., in the Division of Rheumatology. Professor of Medicine Bonita Libman, M.D., led a project in the Division of Rheumatology to eliminate duplicate positive ANA tests, a little-used but expensive antibody test.

Results were monitored for five months, and appropriate changes were made. For example, a letter to providers detailing the latest guidelines, and a change to the request form, helped cut back on unnecessary bone density screenings. For nephrology, education and potential changes to the electronic health record system stand to help reduce the number of unnecessary tests.

One goal is to have residents and fellows involved as much as possible as the next round of projects is launched, Hood says. Stinnett-Donnelly presented the department’s Choosing Wisely campaign at several conferences including the American Association of Medical Colleges meeting in June of 2012.

“What we’re doing here is being recognized nationally,” Hood says. “We could be the model for others.”