How Choosing Wisely Reduces Low-Value Care

An award-winning Group Health partnership is finding the right balance between too much and too little care. Kim Wicklund and Dr. Angie Sparks explain how.

by Kim Wicklund, MPH, and Angie Sparks, MD

For inspiration about how to fix our broken health care system, you might look to the prolific Greek philosopher, Aristotle, and his concept of the Golden Mean. The Golden Mean is “the desirable middle between two extremes, one of excess and the other of deficiency,” according to the New World Encyclopedia. The Golden Mean isn’t the average between extremes, but a balance that depends on the situation. A commonly used example is the virtue courage, which manifests as recklessness when in excess, and as cowardice when deficient.

In health care, we are constantly striving to find the Golden Mean. Every day, clinicians make tough choices about what tests and treatments their patients need. Finding the ideal balance of providing the right amount of care — not too little and not too much — is an ongoing challenge for all clinicians.

The Group Health / Choosing Wisely partnership

As a nation, we have a long way to go to achieve the Golden Mean. While many people don’t have adequate access to care, others get too much care. And more isn’t necessarily better. A 2008 Commonwealth Survey found that one third of adults in the US reported experiencing duplicative or unnecessary care in the previous two years. That type of waste accounts for about 30 percent of total health care costs. In addition to raising the cost of care, “low-value care” contributes to more complications, serious adverse events, anxiety, and other types of harm.

Since 2012, the national Choosing Wisely campaign has been tackling the issue of low-value care. Launched by Consumer Reports and the American Board of Internal Medicine (ABIM) Foundation, Choosing Wisely has partnered with up to 70 medical specialty societies to identify types of care that offer little or no value. They’ve published recommendations, videos, and public service announcements to guide clinicians and patients in avoiding use of low-value care. Their list has over 250 topics and it’s growing. Washington State has established a Choosing Wisely Task Force, led by Matt Handley, MD, the medical director of quality for Group Health.

The Choosing Wisely campaign is strongly aligned with Group Health’s values around affordable, evidence-based, safe care. To understand how to best support our care teams and patients in reducing use of low-value care, a Group Health and GHRI team received grants from Partnership for Innovation and the ABIM Foundation to partner with the Washington Health Alliance, Washington State Medical Association, and Swedish Medical Center to reduce overuse in three areas of low-value care and share best practices across the state. Our three areas are:

Prescribing antibiotics for patients who present with upper respiratory infections (URI)
Most URIs are caused by viruses, so taking antibiotics that stop bacteria but not viruses will not cure the illness. The harms of taking unneeded antibiotics include side effects such as nausea, vomiting, and diarrhea. However, in mid-2015, 41.5 percent of Group Health medical center patients who presented with URI symptoms received antibiotics.

To reduce the prescribing of antibiotics for patients with URI, our team is highlighting the risks of antibiotics and helping clinicians have conversations with patients about antibiotic use and home treatment for URI. Clinical teams from a Renton, Wash. primary care clinic and an Olympia, Wash. urgent care and walk-in clinic participated in a workshop to design clinical workflow and tools for this campaign. The products of the workshop were posted in an online toolkit for Group Health providers that includes scripting, documentation, patient education, and other tools. Since January, we’ve been encouraging use of the tools and sharing monthly reports with providers that compare their rates of prescribing antibiotics for URI with their peers. That transparent data facilitates sharing of best practices among clinicians and tracks improvement.

Unnecessary imaging in patients who present with uncomplicated headaches
For most headaches, tests such as CT scans usually do not help doctors find the cause and relieve symptoms. It is estimated that one to two percent of cancers in the U.S. are caused by ionizing radiation. Yet, in mid-2015 about 13.7 percent of Group Health medical center patients who presented with uncomplicated headache received imaging for their symptoms.

Our team is working closely with Group Health Urgent Care and Neurology to reduce the use of these imaging exams. To date the work has largely focused on using quarterly peer comparison reporting of the rates at which providers order high-end imaging for uncomplicated headaches. That reporting stimulates conversations about the variation in rates and the drivers behind the variation. The goal is to support a learning community that gradually helps us achieve a golden mean.

Too-frequent Pap smears
National and Group Health guidelines say that most women should get cervical cancer screening every few years, not annually. Women under age 21 and most women over 65 don’t need this test at all. At Group Health in mid-2015, more than 14 percent of Pap tests were done too soon.

We’ve worked with Group Health Women’s Health and Primary Care to reduce the rate of women who get a Pap sooner than 30 months since their previous test. Group Health offered providers Continuing Medical Education about the Pap clinical guidelines, including the harms of too-frequent tests, and how to use Choosing Wisely handouts on this topic. We’ve built a trigger tool that enables us to leverage our data systems to notify providers when Paps are done too soon. Biannual peer-comparison reporting supports conversations on how to reduce overuse in this area.

Our progress to date

Since early 2015, we’ve seen the following results:

• 27.5 percent reduction in antibiotics for URIs;
• 4.4 percent reduction in imaging for uncomplicated headaches;
• 11.9 percent reduction in too-frequent Paps. This improvement is in addition to a previous 26 percent reduction under a Partnership for Innovation grant led by Dr. Handley and Group Health Research Institute Senior Investigator Diana Buist, PhD, MPH. This work was funded by Group Health’s Partnership for Innovation.

The crosscutting components of our work to reduce low-value care in the three focus areas include:

• Getting buy-in from health care system leadership to establish the work as a priority;
• Developing evidence-based clinical messaging;
• Offering providers training, tools, Continuing Medical Education opportunities, and scripting to address patient concerns;
• Introducing Choosing Wisely materials into clinical workflow;
• Transparently sharing peer-comparison rates;
• Supporting a learning community.

We are midway into our grant and are already sharing some of our strategies. In fact, Angie recently presented these results to the National Alliance of Healthcare Purchaser Coalition meeting, where Group Health received the group’s 2016 eValue8 Innovation award for this work. You can learn more about our work to share Choosing Wisely strategies at this website.

Also, we are beginning to recognize that the strategies we’ve applied to these topics are transferable to other types of low-value care. Group Health leadership, staff, and providers, and Group Health Research Institute investigators are all working toward the same goal. We’re committed to the Golden Mean of health care — not too little, and not too much.

Kim Wicklund, MPH, is a patient engagement manager, and Angie Sparks, MD, is a family physician. Both authors work at Group Health. For more from the Group Health Research Institute see grouphealthresearch.org