by Dr. John Bulger DO, MBA
It has been two years since SHM unveiled its Choosing Wisely lists: 5 pediatric and 5 adult tests and treatments which hospitalist and their patients should question. SHM was quite eager at the time to play a role in the effort to create value by reducing cost and improving quality. In many ways, this is what hospitalists do for a living.
Much effort has been focused on improving value in medicine. In spite of the good intentions, these many initiatives have come and gone with little lasting impact. The ABIM Foundation and SHM both intended for Choosing Wisely to be different!
One of the strategies to accomplish sustainability was a grant, funded by the Robert Wood Johnson Foundation and administered through the ABIM Foundation. SHM proposed to hold a competition, of sorts, to encourage and recognize hospitalists who are implementing changes aimed at reducing utilization in one of the 10 targeted tests and treatments. A second deliverable from the grant is to publish a compendium of Hospitalists Choosing Wisely. This would include participants in the competition and other vignettes of hospitalist groups who are implementing changes in their practice. The goal is to provide a number of examples for hospitalists, in different practice settings, to elucidate how change can happen.
The Choosing Wisely subcommittee was gratified to receive many entries to the competition. We were also impressed with the breadth and depth of the work being done by hospitalists. The response is one piece of evidence suggesting that hospitalists have embraced the spirit of the Choosing Wisely campaign and are using the SHM recommendations, as well as recommendations from other specialties, to improve value to patients. It was difficult to choose “winners” in this type of competition. The real winners are patients! But…several of the submissions singled themselves out…and…we promised cash prizes…
So, without further ado, a little bit about our contestants…
Pediatrics
Honorable mention
Matthew Garber, MD and colleagues from the University of South Carolina School of Medicine recruited 22 hospitals in 12 states to focus on the care of pediatric patients with bronchiolitis. The collaborative actively shared quantitative and qualitative findings. The group decreased the used of bronchodilators, steroids, chest x-rays, and pulse oximetry. All the results were statistically significant.
Sangeeta Schroeder, MD and colleagues at the Ann and Robert H Lurie Children’s Hospital of Chicago submitted two projects. The first aimed to decrease the number of chest x-rays on pediatric patients with bronchiolitis. A multidisciplinary team focused on formulating guidelines and editing order sets. By eliminating chest x-ray orders from the path of least resistance they were able to decrease whole hospital utilization by about one third.
In their second submission, the focus was bronchodilator usage in bronchiolitis. A similar process was followed that led to the decrease of almost 50% initially and subsequent smaller year over year decreases.
Winner: Amanda Schondelmeyer, MD and colleagues at Cincinnati Children’s Hospital Medical Center focused on decreasing the use of pulse continuous oximetry for children with bronchiolitis. They accomplished by this agreeing to best practices, education, engagement, and eventual order set changes in the EHR. Their initial goal was to decrease the median time from 10.7 hours in half to 5.4 hours. In the end, they decreased the median time on continuous oximetry to 3.1 hours, a two-thirds decrease!
Adult
Honorable mention
Kevin Flemmons, MD and colleagues at Vanderbilt University in Nashville tackled the problem of overuse of routine blood tests. The initiative targeted trainees through education, incentives, and just-in-time information on the cost of testing. The effort reduced the % of patients receiving daily labs from 90% of patient to 70% of patients. This amounted to almost 1,500 fewer lab tests or almost 7 liters of blood removed from patients. This submission also highlights the merits of a Housestaff Quality Council.
Manya Gupta, MD and colleagues at Rush University Medical Center in Chicago sought to develop and implement guidelines to decrease blood utilization. They focused on setting parameters for transfusion and limiting transfusions to one unit of PRBCs rather than the “traditional” two. Orders in the EHR were modified. This included the removal of the “other” reason for transfusion. The overall number of transfusions decreased by a third and the number of transfusions in patients with hemoglobin over 8 g/dL decreased by two thirds.
Emily Mallin, MD and colleagues at Banner Good Samaritan Medical Center in Phoenix aimed to decrease the number of red blood cell transfusions. The project sought both to clarify and educate physicians on the criteria for transfusion, focusing on symptoms, and focusing on transfusing one unit at a time. They named the campaign “One is the new Two.” The initiative decreased the rate of transfusion by almost 16% and saved over $400,000 over a year.
Winner: Harry Cho, MD and colleagues at Mount Sinai in New York City focused on the use of urinary catheters and decreasing CAUTI. Their initiative was aptly titled “Lose the Tube” and included the mnemonic NO TUBE (Neurologic (spinal/pelvic) trauma, Obstruction/retention, Tenuous (critically ill CHF or AKI), Urological surgery, Bed sores + incontinence, and End of life) as indications for indwelling urinary catheters. The project included EHR order sets and interdisciplinary rounds. Catheter days were decreased significantly as were the rate of CAUTI (from 16 in the control period to 1 (yes one) during the intervention).
I would like to congratulate all of those who participated. I would also encourage others who are working on similar projects to consider sharing your work with colleagues via the Hospital Medicine Exchange (HMX). Be on the lookout for a completion of all of the efforts in the coming months as we release Hospitalists Choosing Wisely.
Dr. John Bulger DO, MBA is the Chief Quality Officer for the Geisinger Health System. In this role he leads Geisinger’s Division of Quality and Safety and is responsible for leading and disseminating Geisinger Quality.
Dr. Bulger previously served as Director of Geisinger’s Hospital Medicine Service Line. He founded Geisinger Medical Center’s hospitalist model in 1999 and lead the program’s development to include seven hospitals and over 60 physicians.
Dr. Bulger serves on the Society of Hospital Medicine’s (SHM) Healthcare Quality and Patient Safety. Over the last several months he has helped lead SHM’s participation in the American Board of Internal Medicine’s Choosing Wisely Campaign. He is a Clinical Associate Professor of Medicine and Regional Assistant Dean at Philadelphia College of Osteopathic Medicine and an Associate Professor of Medicine at Temple University School of Medicine.
Dr. Bulger is a senior fellow of the SHM and a fellow of the American College of Osteopathic Internists, and the American College of Physicians. He holds leadership positions at several medical organizations and institutions. His wife, Michele is a pediatrician and member of Geisinger’s faculty and they reside in Danville, PA with their children Ethan, Ben, and Ava.
You can follow Dr. Bulger on twitter @johnbbulger.
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