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PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY May 2017 | Archived Issues

Healthcare Leaders Share Lessons from Choosing Wisely

Cedars-Sinai and four other large healthcare providers in California gathered last month to highlight their successes implementing the national Choosing Wisely initiative, which aims to reduce inappropriate medical tests and procedures that can do more harm than good.

Physicians and other leaders from Cedars-Sinai were joined at an April 28 symposium on the medical center campus by colleagues from Los Angeles County + USC Medical Center, Sharp HealthCare in San Diego, Sutter Health in Northern California and UCLA Health.

Through the national initiative, launched in 2012 by the American Board of Internal Medicine Foundation and Consumer Reports, dozens of medical specialty societies such as the American College of Physicians have identified nearly 500 common medical tests and procedures that may not have clear benefit for patients and sometimes should be avoided.

The effort gives doctors real-time information and sparks important conversations with patients about the appropriateness of certain diagnostic tests and treatments. As a result, patients waste less time undergoing tests that do not improve their care or taking medications that will not help.

Some providers, including Cedars-Sinai, have integrated Choosing Wisely recommendations into their electronic medical records systems. Alerts pop up on physicians’ computer screens during patient visits, asking whether specific choices are necessary given a patient’s medical condition and medications, and in light of recently published studies.

"Physicians, clinicians on the ground, know best where the problems are, where the overuse is," Daniel Wolfson, executive vice president and chief operating officer of the American Board of Internal Medicine Foundation, said at the symposium. "I think that what Cedars-Sinai has done is remarkable. You have been the leader. You have had tremendous success."

Unnecessary medical care rings up an estimated $192 billion in annual healthcare spending, according to the Journal of the American Medical Association.

Surveys conducted by Choosing Wisely found that 64 percent of physicians report the initiative empowered them to reduce use of unnecessary tests and treatments. Nearly 65 percent of emergency room doctors felt more comfortable discussing low-value services with patients, while almost 55 percent said they reduced utilization.

"After decades of discussion and debate, physicians, nurses and others responsible for delivering care at the bedside are demonstrating that we can address this problem of inappropriate care where the harms exceed the benefits," said Scott Weingarten, MD, MPH, chief clinical transformation officer at Cedars-Sinai and one of the symposium’s organizers. "By empowering patients and doctors, we can deliver higher quality care more efficiently, increasing the value of healthcare for those who need it most."

At the symposium, leaders from Cedars-Sinai and the other healthcare providers shared their Choosing Wisely experiences and results. Some highlights:

Cedars-Sinai

  • Integrated nearly 100 recommendations into its electronic health record system more than three years ago.
  • Patients of physicians who followed all the alerts had fewer medical complications and left the hospital sooner.
  • When doctors fully adhered to all the alerts, costs dropped by hundreds of dollars per patient encounter. The health system avoided $6 million in healthcare spending in the first full year of its Choosing Wisely implementation.

Los Angeles County + USC Medical Center and UCLA Health

  • Implemented and evaluated a multidisciplinary quality improvement initiative at the Los Angeles County Department of Health Services to reduce low-value preoperative care such as blood tests and electrocardiograms for cataract surgery patients. Most people don’t need such tests before low-risk surgery unless they have certain health conditions or illnesses.
  • Dramatically reduced preoperative testing, freed up staff and provided six additional months of good vision to patients by shortening the wait time for surgery.

Sharp Rees-Stealy Medical Group in San Diego

  • Distributed wallet cards to patients listing "5 Questions to Ask Your Doctor Before You Get Any Test, Treatment or Procedure."
  • Engaged community skilled nursing homes with Choosing Wisely recommendations.
  • Decreased opioid prescribing by 10 percent in one year. Reduced use of unnecessary cardiac stress testing by about 5 percent.

Sutter Health in Northern California*

  • Addressed more than 130 Choosing Wisely recommendations.
  • Engaged more than 3,000 clinicians, supporting 1 million patients, and saved $66 million since 2010 by eliminating avoidable tests and treatments.
  • Decreased the ordering of repeat labs by 20 percent in three hospitals after six months — a rate that has been maintained for two years.

    *Sutter Health achieved some of these results for efforts prior to adopting Choosing Wisely recommendations.