Quality Improvement: Assessing wasteful and unnecessary medical tests and treatments incorporating Choosing Wisely guidelines

From the 2018 HVPAA National Conference

Erin Dunneback (Michigan State University College of Human Medicine), Mark Spoolstra (Mercy Health Saint Mary’s Hospital)

Background

Awareness has grown of the astronomical amount of medical waste in the hospital and the implications this has on patients, employees, and resources. In response, the American Board of Internal Medicine Foundation launched the Choosing Wisely campaign comprising evidence based guidelines to reduce medical waste. This study utilized those guidelines.

Objectives

To improve the quality of care on the Mercy Health Saint Mary’s Internal Medicine service by more faithfully following well accepted guidelines on appropriate use of resources in the hospital setting. It was hypothesized that Mercy Health Saint Mary’s Hospital had a sizeable amount of medical waste in the form of unnecessary medical services ordered or that have not been discontinued when discontinuation is reasonable. The goal was to decrease unnecessary utilization of identified resources by 5% by the end of this project.

Methods

Study timeline was 7/2016-7/2018. Medical students on the Internal Medicine clerkship were instructed how to implement guidelines for reducing waste regarding 6 commonly utilized medical orders (repeat CBC, telemetry, RBC transfusion, IV fluids, supplemental oxygen, and antibiotic therapy). The students reminded the care team of the guidelines and the team decided if any changes in care should be made. The students then recorded, on pre-made checklists, whether the orders were continued or discontinued for each patient. This data was tracked to determine if there was a decrease in the utilization of these orders. The Crimson Database, a hospital wide database used for tracking orders placed by physicians, was also utilized to determine total number of orders placed regarding these 6 orders prior to initiation of this project and throughout.

Results

Preliminary data from 7/2016-2/2018 collected by medical students includes 160 total patient encounters recorded. After discussing the waste-reducing guidelines with the care team the following percentage of orders were discontinued: CBC 6.7%, telemetry 6.8%, RBC transfusion 25%, IV fluids 41.5%, supplemental oxygen 31%, antibiotic therapy 16.8%. Preliminary data from the Crimson Database was available for CBC, telemetry, and RBC transfusion only. From 7/2015-6/2016 (prior to initiation of the study) the total orders placed on the internal medicine service were as follows: CBC 4944, telemetry 65, RBC transfusions 106. From 7/2016-6/2017 (after initiation of the study) the total orders placed were as follows: CBC 6448, telemetry 102, RBC transfusion 161. From 7/2017-12/2017 the orders were as follows: CBC 1648, telemetry 41, RBC transfusion 41.

Conclusion

Preliminary data demonstrates that, in some cases, when the care team is reminded of the Choosing Wisely guidelines, orders are subsequently discontinued. However, the Crimson Database demonstrates an increase in total number of orders placed after initiation of the study. Further data analysis is necessary to determine the impact of this study.

Implications for the Patient

Medical waste, in the form of unnecessary orders placed or orders not discontinued when reasonable, is detrimental to patient care. Not only does it increase cost for patients and health systems, but it subjects patients to undue tests and treatments that have potential consequences. It’s imperative to reduce medical waste.