University of Vermont

College of Medicine

Department of Medicine

Choosing Wisely: a DOM initiative for improving value

As health care costs soar it has become apparent that physicians need to lead the effort to preserve quality, while reducing harm and cost to ensure that patients get the value they deserve.

Launched in 2011 were the National Physicians Alliance “Top 5” in Internal Medicine and the American College of Physicians High-value Cost Conscious Care Initiative with the goals of developing and collating evidence about the real value of diagnostic tests and treatments in order to build programs to educate physicians, trainees and patients. As an extension of these initiatives, in April 2012 the American Board of Internal Medicine Foundation convened a group of 9 national medical specialist organizations and Consumer Reports to mobilize an effort nationally. The stated aim was to reduce overuse or misuse of tests and procedures that provide little benefit or can harm. This “Choosing Wisely” campaign has now been embraced by more than 25 medical groups and 13 consumer-oriented organizations.

A few months later, the DOM at FAHC began local implementation. Our goal is to identify, measure and ultimately eliminate low value tests and procedures that we control. In addition we hope to create a scalable process model which can be applied in other departments or other academic medical centers to reduce harm and preserve finite medical resources.

Dr. Parsons, key faculty, administrative and quality directors met to discuss goals and strategy including how to integrate any effort into education and research. Unit Directors and their faculty were asked to propose tests they felt were overused, misused, futile or harmful. With 22 suggestions from 9 units the DOM Operations Efficiency Committee chose 4 using the criteria that each test would be noncontroversial and its use evidence-based; have a reliable measure and one available electronically; that its introduction or elimination would add value by reducing harm or cost, improving patient outcome or experience and very importantly, any intervention would not increase physician workload.

To implement the program we identified physician champions, recruited several residents and fellows, harnessed the skills of the Jeffords Institute for Quality personnel and interacted with FAHC laboratory and PRISM staff. Justin Stinnett-Donnelly MD, PGY3 and Patricia Bouchard RN MS CPHQ are the key people leading this effort.

The first 4 projects included ones in Nephrology, Rheumatology and Gastroenterology.

1. Reduce or eliminate unnecessary measurement of serum creatinine, BUN, lytes on patients with ESRD receiving dialysis admitted to the hospital.

2. Do not repeat an ANA if a prior ANA has been positive.

3. Do not order a bone density scan on women

4. Do not order a screening colonoscopy on patients >75 years old or who have had a percutaneous coronary intervention (stent) placed within the last 6 months.

Preliminary results show that almost 4000 serum creatinine along with over 19000 BUN and electrolyte panels were obtained on patients with ESRD admitted to FAHC over a recent 2 year period. While there is zero value for the measurement of serum creatinine in this group of patients, it is also likely that the majority of the other testing did not improve patient outcomes or experiences but certainly incurred costs. We are working on a solution that will leverage the strength of our electronic health record to change ordering practices.

Screening colonoscopy criteria are generally being met but there is room for improvement as well as efforts to encourage appropriate use for those who may benefit. Work with Rheumatology is underway to improve ordering practices for ANAs and DEXA scans.

Our future plans are to use lessons learned from these initial projects to identify further candidates for practice change. We also need to develop ways to define upfront and downstream cost in a formal manner; document other savings such as less patient discomfort or blood loss, better patient satisfaction and system efficiencies; generate lasting resident and fellow interest in these projects; develop low manpower systems to continuously monitor the targeted practice patterns; and maintain momentum.