Choosing Wisely Champions Project Archive
Explore the projects below to learn about successful approaches for eliminating costly and potentially harmful overuse of tests and procedures.
Carol M. Mathew, MD
Affiliation: University of Florida, Gainesville, Florida
Reducing Unnecessary Pre-medication Prior to Parenteral Iron Therapy
Kamal Kant Sahu, MD
Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, United States
Implementation of New Electronic Medical Record Algorithm to Streamline the Appropriate Use of Rasburicase
Daanish Hoda, MD
Intermountain Healthcare, LDS Hospital, Salt Lake City, Utah
Decreasing the rate of Clostrididoides difficile infection (CDI) overdiagnoses and treatment by instituting and algorithm for clinician’s to follow prior to testing.
A hospital-acquired Clostridioides difficile infection (CDI) is typically diagnosed in the presence of diarrhea associated with a positive stool test for CD toxin and/or toxin genes. However, these criteria carry the risk for overdiagnosis for inpatient populations, such as hematopoietic stem-cell transplant recipients (HSCT), who have high frequencies of diarrhea of other causes and CD colonization. Overdiagnosis and treatment of CDI leads to unnecessary costs, toxicities, and the risk of hospital penalties imposed by CMS.
In September 2018 we introduced an algorithm designed to reduce CDI overdiagnoses and treatments. The incidence of stool submissions for CD analysis decreased from 36.6/1000 inpatient days (ID) for the 2 years prior to 20.6/1000 ID for the 3 years following introduction of the algorithm (p<0.001) and the number of CDI diagnosed and treated from 5.5 to 2.4 /1000 ID (p=0.009). Comparisons at transplant day 100 for first auto-HSCT and first allo-HSCT cohorts admitted during the 2 study periods showed no decreases in overall survival or increases in transplant admission lengths of stay or readmission rates associated with algorithm introduction.
Thomas Bodley, MD
Affiliation at Time of Research Study: St. Michael’s Hospital, Toronto, Ontario
Current Affiliation: Sunnybrook Health Sciences Center, Toronto, Ontario
Reducing unnecessary and repetitive diagnostic phlebotomy in an intensive care unit: a quality improvement study
The work of Dr. Bodley and colleagues at St. Michael’s Hospital demonstrates that improvement interventions can reduce serial blood draws in the ICU. In the intensive care unit (ICU), blood testing is an essential component of diagnosis, monitoring, and treatment. However, many ICU blood tests are reflexive and unnecessary, and blood loss from repeated blood tests can cause those in the ICU to need red blood cell transfusions, develop ICU acquired anemia, or need to extend their stay in the hospital. In their study, Dr. Bodley and colleagues aimed to reduce the amount of blood taken from patients each day by 15%, as well as to reduce the number of discrete blood draws per patient per day. They implemented a series of strategies to achieve this aim, including education sessions, workflow changes, implementation of add-on testing, and electronic order set modifications. As a result, the mean blood volume decreased from approximately 41 mL per patient-day to approximately 35 mL per patient day. The number of blood draws per patient per day also decreased, from an average of 3.2 draws to an average of 2.8. The work of Dr. Bodley and colleagues demonstrates that improvement interventions can reduce serial blood draws in the ICU. Dr. Bodley is now affiliated with Sunnybrook Health Sciences Centre, however, this work was completed at and supported by St. Michael's Hospital, Toronto, Ontario.
Matthew T. McEvoy, MD
Texas Children’s Hospital, Houston, Texas
A risk-adapted approach to reduce variability and optimize management for pediatric nutritional iron deficiency anemia in the emergency department
Dr. McEvoy and colleagues saw that emergency departments lacked a consistent, systematic approach to managing care among children younger than five years old being admitted for iron deficiency anemia. As a result, children were receiving inappropriate laboratory evaluations, unnecessary transfusions or hospital admissions, and suboptimal administration of oral or intravenous iron. To standardize and improve care for these patients, Dr. McEvoy and colleagues created a novel clinical algorithm accounting for risk based on anemia severity. With input from leading experts in hematology, emergency medicine, transfusion medicine, inpatient nursing, and departmental quality oversight committees, the team formalized and implemented the algorithm into clinical practice. Use of the algorithm by providers led to an increase in several outcome quality measures, including optimal laboratory evaluation (increased from 42.5% to 71.4%), therapy choice (increased from 77.5% to 100%), optimal therapy administration (increased from 50.0% to 83.3%) and disposition guidelines (increased from 84.8% to 100%).
Srila Gopal, MD
University of California, San Diego
Establishing same day infusion treatment protocols for uncomplicated sickle cell vaso-occlusive crises using a telemedicine platform
Individuals living with sickle cell disease (SCD) experience vaso-occlusive crises (VOC), a common painful complication that occurs when sickled cells cluster together and obstruct the flow of blood in the body. An individual with SCD may seek care in the emergency department for a VOC, but early, adequate treatment of pain in an outpatient-based infusion center (IC) setting is key to avoiding hospital visits. During the COVID-19 pandemic-related shutdowns, Dr. Gopal and colleagues recognized that they would need an alternate way to keep these patients getting their necessary care. They created a telemedicine platform to continue IC treatment with a multi-disciplinary team of providers including a nurse case manager, advanced practice provider, doctor, IC scheduler, and IC charge nurse. After implementation of the telemedicine approach, and optimizing their workflow, IC visits increased (579 visits as compared to 546 visits), and emergency department visits decreased (132 visits as compared to 162 visits). The work of Dr. Gopal and colleagues represents an effective strategy that smaller sickle cell programs, including those with limited resources, can implement and use.
Arielle L. Langer , MD, MPH
Brigham and Women's Hospital, Boston, Massachusetts
Reducing Unnecessary Thrombophilia Testing
Patients with venous thromboembolism (VTE) are often subjected to extensive laboratory testing, despite the fact that it usually should not impact management. Dr. Langer and her team were concerned both that positive results could lead to excessive anticoagulation and negative results could lead to withholding of needed anticoagulation. To reduce testing, the team developed a consensus testing algorithm, which was rolled out with an educational campaign. In order to make default practices less likely to deviate from these guidelines, they also implemented order sets changes. After these interventions, there was a 17.1 percent reduction in overall testing (p = 0.007). The greatest reduction was in the outpatient practices of the hematology/oncology division, which showed a 45.9 percent reduction (p = 0.007). Due to the high cost of these tests, the reduction in testing resulted in $31,626.82 saving per month without comprising patient care.
Hind Salama, MD
King Abdulaziz Medical City
Reducing Futile Acute Care Services for Terminally Ill Cancer Patients: The Dignity Project
The dignity project is a quality improvement project held at King Abdul-Aziz Medical City-Riyadh/Saudi Arabia with an aim to reduce the utilization of futile acute care services (ACS) for cancer patients treated with a palliative intent approach.
This was pursued by implementing an intervention model with an aim to achieve the teams' goal. The main components of the model were: multidisciplinary meetings to decide and document the goal of treatment for each cancer patient, delivery of educational sessions to the staff, patients, and their families; implementation of mandatory documentation of the goals of care in the electronic healthcare record system, and early referral to palliative care. Following the intervention period, the usage of ACS documentation of goal of care and overall cost had significantly improved.
Sriman Swarup, MD
Texas Tech University Health Sciences Center, Lubbock, Texas
A restructured approach to the diagnosis of Heparin Induced Thrombocytopenia (HIT)
The prevalence of 4T scoring before ordering of HIT screening antibody test was reviewed over one year retrospectively at a large tertiary academic hospital. 4T scoring was incorporated into the electronic medical record and was made a compulsory part of the HIT workup, with post-intervention prevalence noted. The antibody screening test done at the hospital was outdated (Platelet Immuno-Filtration assay) and replaced with a new HIT screening antibody test (Latex Immunoassay). Dr. Swarup and his team's intervention led to improved use of 4T scoring system, which translated to the reduction of inpatient stay, alternative anticoagulation used, and healthcare expenditure in the target population six months post-intervention.
Rachael F. Grace, MD
Boston Children’s Hospital, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts
Recommendations for Newly Diagnosed Children with Immune Thrombocytopenia (ITP)
Dr. Grace and her colleagues developed a learning algorithm to unify the approach to the management of newly diagnosed children with immune thrombocytopenia (ITP). An observational approach is recommended in newly diagnosed children with ITP with no or mild bleeding; however, these children are often treated with medications likely related to both physician and family anxiety. This practice leads to many children being treated with medications who could otherwise be safely observed in the outpatient setting leading to over-utilization of resources including ER visits, inpatient admissions, medication administration, and encounters for management of medication-related side effects. Dr. Grace and her colleagues instituted an algorithm for the management of newly diagnosed ITP after a review of the center’s data revealed wide practice variation with overtreatment of children with no or mild bleeding and poor adherence to national guidelines. Since inception, the algorithm has unified this center’s initial laboratory approach, treatment decision-making based on bleeding score, and timing of follow up. Implementation of the initial algorithm made no impact on observation rates, which led to a second iteration in which the algorithm was modified to further stratify high and low risk bleeding symptoms. With this change, initial observation rates increased from 40 to 87 percent with no increase in bleeding complications, demonstrating that a management algorithm for newly diagnosed ITP can improve the consistency of care and increase the rate of adherence to national guidelines.
Jordan K. Schaefer, MD
University of Michigan, Dexter, Michigan
An Intervention to Reduce Inappropriate Aspirin (ASA) Use Among Patients on Warfarin
Dr. Schaefer and his colleagues completed a study of patients anticoagulated with warfarin for atrial fibrillation and/or venous thromboembolic disease that compared clinical outcomes based on whether or not patients were on concomitant aspirin therapy (PMID 30830172). They found that for some patients, adding aspirin to warfarin was associated with a significantly higher incidence of bleeding but did not seem to protect patients from adverse thrombotic outcomes. As a result, the Michigan Anticoagulation Quality Improvement Initiative (MAQI2, www.maqi2.org) developed an intervention to reduce the number of warfarin treated patients on aspirin without a clear indication. The intervention was implemented at six diverse anticoagulation clinics throughout the state of Michigan between late 2017 through early 2018. Patients on warfarin and aspirin were identified. If they did not have an apparent potential indication for aspirin therapy (e.g. coronary artery disease, a history of myocardial infarction, etc.) their managing doctor was contacted to assess if the patient still needed to be on aspirin. If the patient’s doctor felt that the risk of ongoing aspirin use exceeded the anticipated benefit, the anticoagulation clinic would contact the patient to suggest discontinuing aspirin therapy. Between the third quarter of 2017 and the second quarter of 2019, inappropriate aspirin use was reduced by 48.8%, from 24.6% of patients to 12.6% (P<0.001).
Stephen L. Wang, MD
Division of Vascular and Interventional Radiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
Reduction in IVCF Utilization and Increase in IVCF Retrievals
As an interventional radiologist, Dr. Wang treated several patients for sequelae of long-term inferior vena cava filters (IVC filters). Dr. Wang and his team developed a system to address major concerns with IVC filters, mainly overutilization and lack of follow-up/filter retrieval. This comprehensive IVC filter clinic model consisted of three major parts: 1. Educating ordering physicians on appropriate use of IVC filters to reduce overutilization, 2. Tracking IVC filters using a novel tracking tool to increase follow-up and retrieval rates, and 3. Developing a specialized group of operators with additional expertise for complex IVC filter retrievals. Multi-disciplinary participation was critical in this approach. Interventional radiology was the lead service with overall responsibility along with active participation by hematology, hospital-based medicine, pulmonary/critical care, surgical subspecialties, the controller’s office and the anticoagulation clinic.
Initially piloted at Dr. Wang’s home facility, the project advanced to full regional deployment across Kaiser Permanente Northern California (21 hospitals serving over 4.3 million members). Fourteen evidence-based, in-hospital grand rounds were given by Dr. Wang and a regional IVC filter tracking tool was simultaneously deployed at all facilities. Over a 2-year period, IVC filter utilization across 14 medical centers decreased by 18.7% and individual facility reduction correlated with Grand rounds attendance. After the intervention, IVC filter retrieval rates across the northern California region increased from 38.9% to 54.0%. The IVC filter tracking tool was recently updated as an automated, integrated tracking module within Kaiser Permanente’s electronic medical record.
Adam F. Binder, MD
Thomas Jefferson University Sidney Kimmel Cancer Center, Philadelphia, Pennsylvania
Reduction in inappropriate vancomycin prescribing for febrile neutropenia
While he was an attending physician at the Montefiore Medical Center in New York, Dr. Binder and his colleagues developed a process improvement initiative to encourage the appropriate use of IV vancomycin, an antibiotic, for patients with neutropenic fever over a 10-month period. Dr. Binder decided to tackle this issue after a preliminary examination of antibiotic use at his institution revealed clinicians were overprescribing vancomycin for neutropenic fever based on existing guidelines. This revelation led to interdisciplinary discussions between the antibiotic stewardship team, pharmacists, and hematologists. The team developed an institutional algorithm to guide prescriptions related to febrile neutropenia and conducted recurring educational initiatives emphasizing criteria for appropriate vancomycin initiation based on well-established guidelines. Post-intervention, appropriate prescribing of vancomycin increased to 66 percent (from 49 percent pre-intervention), demonstrating that interdisciplinary development of an algorithm for management of neutropenic fever can improve the appropriate use of antibiotics.
Ming Lim, MD
Medical University of South Carolina, Charleston, South Carolina
Reduction in use of direct thrombin inhibitors (DTIs) in patients with suspected HIT
Dr. Lim’s project was developed to address inappropriate testing and care of patients with suspected heparin-induced thrombocytopenia (HIT). At her institution, she realized that many patients were being tested for HIT despite having a low pre-test probability with the 4T score, a risk predictive model with a high negative predictive value. Further, in patients that did test positive for HIT through a diagnostic test, a minority were subsequently being confirmed with a more specific test, the serotonin-release assay (SRA). In addition, non-heparin anticoagulants (direct thrombin inhibitors or DTIs) were being administered needlessly, in many cases, for several days until the SRA assay results were available. A root cause analysis found that there were inconsistencies in the way tests were being ordered and management of patients suspected of having HIT by physicians. There was also no system in place for the Anticoagulation and Bleeding Management Service team to be alerted on a daily basis for patients suspected of having HIT. The implementation of a centralized hospital-wide protocol that coordinated testing and treatment of patients suspected to have HIT led to improved testing and management of patients, as well as a substantial reduction in the use of DTIs (78%).
Prakash Vishnu, MD
Mayo Clinic, Jacksonville, Florida
Reduction in Unnecessary Red Blood Cell Transfusion in HSCT Patients
Dr. Vishnu and his team investigated the theory that transfusing one unit of red blood cells instead of two would be appropriate for hemodynamically stable adult hospitalized patients undergoing myeloablative chemotherapy (MC) and autologous hematopoietic stem cell rescue (AHSCR) who have a hemoglobin level of greater than or equal to seven grams per deciliter. In early 2017, the team designed and set up an electronic medical record-based restrictive red blood cell transfusion program as part of a quality initiative at Mayo Clinic Florida’s hematopoietic stem cell therapy center. Clinicians, hematology trainees, and nurses were educated about this program with weekly didactic sessions, pamphlets, and verbal instruction for two months. Data from 2017 were compared to those of a similar group from 2016 and showed a significant decrease in the total number of red blood cells transfused (28 units in 2017 versus 71 in 2016). Overall, there was no difference in time to engraftment between those who received red blood cells and those who did not, but the incidence of sepsis was much higher (70.7 percent versus 51.5 percent) and there was a trend towards longer hospital stay (16 days versus 14 days) among those who received red blood cells.
Yulia Lin, MD
Sunnybrook Health Science Centre/Research Institute
Reduction of inappropriate transfusions for patients with iron deficiency anemia in the emergency department via guidelines and physician education
After observing a patient, who was eventually determined to have iron-deficiency anemia (IDA), repeatedly visit the emergency department and receive repeated transfusions, Dr. Yulia Lin and colleagues worked to reduce inappropriate transfusions for patients with the same condition. The team used several interventions, including conducting an education session, creating an algorithm on IDA management, and implementing a toolkit for emergency department physicians. They also made intravenous (IV) iron more readily available in the emergency department, improved access to a transfusion specialist for guidance, and presented on the topic at rounds. The result was a significant improvement over the baseline, with transfusion appropriateness improving from 53 percent to 91 percent between January 2014 and December 2015. The use of IV iron increased from an average of 2.4 uses per month in 2014 to 4.8 uses per month in 2015.
Learn more about this project in the associated paper, “Improving quality of care for patients with iron deficiency anemia presenting to the emergency department,” published in Transfusion.
Matthew Schefft, DO
Children’s Hospital of Richmond at Virginia Commonwealth University
Reduction in admission rate for children with SCD presenting with vaso-occlusive crisis via initiation of individualized pain plans
Dr. Matthew Schefft and his colleagues used individualized pain plans (IPPs) to reduce pediatric emergency department admission rates for children with sickle cell disease (SCD) presenting with vaso-occlusive crisis (VOC), a frequent event for children with the disease. Dr. Schefft's project brought together a multi-disciplinary team that used a "Plan-Do-Study-Act" (PDSA) format to add an IPP document to the electronic medical record and create IPPs for the highest resource users. The team then measured the presence of an IPP, adherence to the IPP, and time to first and second opiate dose administration. The primary outcome was a decrease in the admission rate of 28 percent among patients with an IPP compared with the prior year. Even though there was no difference in readmission rate or 72-hour return rate to the emergency department, the project avoided an estimated 49 admissions per year and reduced costs for the hospital and patients.
Marc S. Zumberg, MD
University of Florida
Systems-based hematology: Improvement of compliance and utilization of recombinant Vlla, prothrombin complex concentrates, and blood products
Dr. Marc Zumberg and his colleagues worked with the College of Pharmacy and local blood bank to create institutionally approved indications for use of recombinant Vlla (rVlla), prothrombin complex concentrates (PCCs), and blood products. They also developed guidelines for the immediate reversal of anticoagulant-related bleeding and for patients on anticoagulants needing emergency surgery. When rVlla, PCCs, or blood products are ordered, an automatic review is triggered that prompts the clinician to indicate the reason for the order. The order is then reviewed by the pharmacy director or blood bank medical directors. If usage is outside of the guidelines, the order is sent to Dr. Zumberg, and he or his colleagues email an individualized letter to the ordering clinician explaining why usage did not meet institutional guidelines. During the last three years, the letters have decreased expenditures related to inappropriate ordering by $590,830 and increased compliance with the University of Florida's blood transfusion guidelines.
Maria Juarez, MD
Baylor Scott & White Health, Cancer Institute of Dallas
Reduction of RBC transfusion via updated guidelines, modified workflow, and physician education
To combat variability in blood utilization across hospitals in the Baylor Scott & White Health system, Dr. Maria Juarez and her colleagues developed an institutional clinical practice recommendation based on published red blood cell utilization guidelines, modified transfusion workflow in the electronic health record, and launched a “Why Give 2 When 1 Will Do?” educational campaign. With these collective interventions, the number of single unit transfusions increased by approximately 17 percent during the program period. Single unit transfusions now comprise nearly 57 percent of all red blood cell transfusion orders in the hospital system. Documentation of hemoglobin levels prior to transfusion also improved.
Javier Munoz, MD
Banner MD Anderson Cancer Center
Reduction of post-treatment scanning using EMR alerts
To avoid potential harm from over-testing patients, Dr. Javier Munoz and his colleagues implemented an electronic medical record intervention designed to test whether the introduction of an automatic alert would remind clinicians to carefully weigh the anticipated benefits versus the risks of post-treatment imaging scans for patients with lymphoma. Although the study is ongoing, the automatic alert has reduced the overall number of imaging studies. The average number of monthly scans fell to 25.3 per month over the course of the first three months of the study versus an average 48.3 scans per month in the eight months prior to the introduction of the intervention.
Ravindra Sarode, MD
University of Texas Southwestern Medical Center
Reduction in unnecessary or misapplied thrombophilia testing in patients with DVT, PE, or other thrombotic disorders using combination of education and EMR alerts
Dr. Ravindra Sarode and his colleagues discovered that approximately 85 percent of thrombophilia tests at UT Southwestern’s two teaching hospitals were ordered incorrectly or incompletely. Thrombophilia tests are frequently ordered (usually by non-hematologists) for patients with acute thrombotic events, often while the patient is on anticoagulation therapy. Sometimes, additional variables can cause these tests to return false positive results, which are not always checked for reproducibility or accuracy, causing some patients to be inappropriately placed on long-term anticoagulation therapy. To promote appropriate use of testing, Dr. Sarode’s team developed local guidelines and implemented them in the electronic medical record requiring providers to answer a series of cascading questions before ordering tests. After implementation of the intervention and an associated education campaign, UT Southwestern’s two teaching hospitals reduced thrombophilia testing for inpatients by more than 90 percent.