To help disseminate its own message, the Providers for Responsible Ordering (PRO) group at Johns Hopkins has handed out pocket cards summarizing best practice guidelines, compiled literature reviews, and other educational resources on its website. One recent PRO-backed project used a three-phase process to dramatically reduce unnecessary cardiac enzyme testing at the medical center.7
First, the group gave physicians informational pocket cards. Next, one of the group’s leaders, assistant professor of medicine Jeffrey Trost, MD, gave grand rounds and presented guidelines suggesting no creatine kinase (CK) or CK-MB tests for patients suspected of having acute coronary syndrome, and no more than three troponin tests except in rare circumstances. Finally, the medical center removed CK and CK-MB altogether from its standard physician order entry. As a result, the total orders fell by 66% in the first year, saving an estimated $1.25 million in patient charges.
Internal medicine resident Sonali Palchaudhuri, MD, another PRO member at Hopkins, says an evidence-based approach isn’t always simple. “But our goal with PRO is, 1) to make sure that the evidence is at everyone’s fingertips to at least tailor their decisions based on the evidence that’s out there, and 2) to encourage an environment where we are looking for the evidence more than remaining in the state of practice [that existed] before we knew some of the newer data,” she says.
Other efforts like the Do No Harm Project are helping both medical trainees and attending doctors “celebrate restraint” by emphasizing problem solving that focuses more on what is probable than on what is possible.
“On rounds, an attending might say, ‘Why didn’t you order that or do that?’” Dr. Combs says. “Sometimes, it’s the right thing to do. But not often enough do we say, ‘Good job. I’m glad that you didn’t get that, because that wasn’t necessary, and here’s why.’”
Researchers, meanwhile, are helping to sharpen the distinctions between low and high-value care. “The progression has been first to define what constitutes low-value care, then develop measures of low-value care, both to understand its prevalence and to what extent it’s a problem,” says William Schpero, a PhD student in health policy and management at Yale University. The next step, he says, will be using these measures to inform and evaluate quality improvement efforts at the hospital or clinic level and to provide feedback for physicians working to reduce low-value care within their practices.
Many physicians warn that diplomacy and good communication are essential for getting buy-in from providers. Instead of framing their projects as efforts to reduce unnecessary care, for example, Dr. Moriates and colleagues have described them as stewardship projects designed to ensure that providers are following the best guidelines and providing exceptional patient care.
“Suddenly, everybody can rally around that, because everybody wants to provide the best care,” he says. “And so you’re giving people an opportunity to give the best care rather than taking away something that they have, like transfusions.”
Likewise, framing an issue primarily in financial terms without emphasizing its toll on patients can put many physicians on the defensive.
“We don’t like to think of ourselves as being motivated by cost,” Dr. Combs says. He also urges caution when discussing high-value care. “When a person, especially a lay person, hears ‘value,’ I think it’s very easy to construe that as cost savings or reducing costs or doing it on the cheap,” he says. Instead, when talking to medical trainees, he likes to define high-value care by quoting Bernard Lown, MD, founder of the Brookline, Mass.-based Lown Institute: “As much as possible for the patient, as little as possible to the patient.”