Seattle health system peeks behind requests for unneeded care

Tanya Albert Henry , Contributing News Writer

Direct-to-consumer advertising and readily available medical information online has led to more patients asking for a specific medication or treatment. Echoing the sentiments of physicians nationwide, clinicians at Group Health Cooperative, an integrated health system headquartered in Seattle, worried they would disappoint patients if they didn’t give them the tests or treatments they wanted. But when leaders at Group Health took a closer look at patient requests, they found there was more to the story.

Often, they found, patients weren’t demanding a specific test or treatment. Instead, patients wanted a better explanation of risks, benefits and alternatives for the next steps in their treatment.

With that knowledge, Group Health leaders turned to the Choosing Wisely campaign to improve communication with their patients and to help physicians avoid ordering unnecessary tests or medications. Choosing Wisely recommendations were created “by clinicians for clinicians” with the help of 70 professional societies, as highlighted in an AMA STEPS Forward™ module. The Choosing Wisely initiative covers tests, treatments and procedures commonly encountered in a variety of specialties.

The campaign from the American Board of Internal Medicine Foundation and Consumer Reports promotes conversations between physicians and patients to choose care that is:

  • supported by evidence
  • not duplicative of other tests or procedures the patient already received
  • exposing patients to the lowest possible risk for harm
  • truly necessary

Group Health first helped physicians and other providers change their perspective on the situation. For example, they asked physicians to look at patient requests for unnecessary treatment as partially informed inquiries, not a demand for services. Clinicians were encouraged to listen and show empathy to the patient, acknowledge symptoms and ask what could be done to manage discomfort. Then the physician provided better information and educated the patient.

Group Health targeted specific areas where they wanted to see improvements. In the primary care setting, they aimed to reduce overuse of Pap tests and antibiotics for upper respiratory infections. The emergency department, urgent care and neurology clinics focused on reducing unnecessary imaging for headaches.

Group Health created an easy-to-understand Choosing Wisely website, co-branded with Consumer Reports, for patients. Many clinics also handed printed  Consumer Reports Health materials directly to patients instead of relying on them to take the information from a display.

For Pap tests, the clinic added an electronic trigger tool that flagged when such a test was being ordered too frequently for a patient, along with information for the physician to explain why a Pap test isn’t recommended. The physician also received an email within a week of ordering a Pap test that wasn’t medically necessary.

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Since implementing the Choosing Wisely campaign, Group Health has seen lower prescribing rates and better patient experiences in the exam room. For example, there has been a 33 percent drop in inappropriate Pap tests and imaging for headaches.

The STEPS Forward module offers five steps to follow to help your practice implement a Choosing Wisely campaign:

Engage your providers. Let physicians know this program is about patient safety and patient-centered care; don’t focus the conversation on waste and cost reduction. Also, emphasize the approach as a conversation starter, not a mandate on how to treat patients. Let physicians know that medical decision-making is based on a patient’s best interest and the physician’s professional judgment.

Engage your staff. Consider having clinical-support staff give patients Consumer Reports’ Choosing Wisely campaign brochures related to the reason they are seeing the physician, such as a sinus infection, lower-back pain or cancer screening. Reading a handout on sinusitis while waiting to be seen may make the patient more agreeable to a non-antibiotic treatment.

Engage your patients. Choosing Wisely’s success relies on engaging patients in talking about the purpose of tests, treatments and procedures. The goal is for patients to clearly understand what is necessary, what’s not necessary and what could cause them harm. Show empathy for the patient’s desires, needs and concerns.

Establish an implementation plan. Choosing Wisely can be tailored to best fit your organization’s needs. Some practices may want to increase awareness and make handouts available to patients; others may offer a formal education program for clinicians and staff and have checklists and protocols to standardize the process. Some practices may work with the information technology department to embed Choosing Wisely recommendations into clinical decision-support tools in the electronic health records (EHR) system.

Choosing Wisely has created physician communication modules to help educate doctors about the initiative. The modules are targeted toward physicians specializing in family medicine, pediatrics, cardiology, radiology and more.

Use data to understand and improve performance. Track and report data gleaned from sources such as your EHR, pre-printed order sheets and standing orders from team members. Target the tests you believe may be overused, inconsistently used or harmful to patients.

The STEPS Forward module offers even more detailed information to help practices learn about Choosing Wisely. In addition to walking you through the five steps, it answers frequently asked questions about the campaign and offers tools and resources to implement Choosing Wisely.

This module may be completed for continuing medical education credit. There are seven new modules now available from the AMA’s STEPS Forward collection, bringing the total number of practice improvement strategies to 43; several thanks to a grant from, and collaboration with, the Transforming Clinical Practices Initiative.