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Physicians and Residents Climbing the Mt. Everest of Medical Waste
The ABIM Foundation’s “Putting the Charter into Practice” grant program is focused on advancing stewardship in health care delivery systems. In 2011, we awarded five grants of $20,000 each, and we’ve been excited to see the tremendous return on this investment.
I recently attended Grand Rounds at Johns Hopkins Bayview Medical Center where one of our grantees was presenting their progress to date in their efforts to remove waste from the health care system. Jeff Trost, MD, an attending interventionist cardiologist, and Marc Larochelle, MD, a fellow in general internal medicine at Harvard, presented on their initiative to reduce cardiac biomarkers testing for myocardial infractions (MI, commonly referred to as a heart attack).
I thought the title of their talk, Forget the Fiscal Cliff: Climbing the Mt. Everest of Medical Waste, was poignant and reflected an important point in time for this country. Their initiative is part of a larger program, Physicians for Responsible Ordering (PRO), whose goal is “to reduce laboratory and radiologic testing with no clinical utility or unfavorable risk/benefit ratio (i.e., waste).”
Currently, there are three tests that detect MIs: troponin, the preferred marker of the diagnosis of MI, creatine kinase (CK) or creatine kinase – myocardial band (CK-MB). Clinical evidence suggested troponin alone, administered no more than three times, was optimal care. The downsides of CK and CK-MB are:
- Cost without additive diagnostic utility, and;
- Potentially unnecessary blood draw (although usually troponin, CK and CK-MB are drawn at the same time).
The grantees developed an intervention to provide physicians with information to help them make wise choices in the health care they deliver to their patients – a quick reference guide that directed physicians to obtain troponin only if they suspected acute coronary syndrome (ACS) and only three times if high clinical suspicion (the patient’s symptoms, medical history or ECG suggest a high likelihood of being diagnosed with acute coronary syndrome) was present.
In addition to the educational effort, they embedded the recommendation into their electronic medical records – anytime CK-MB or CK was ordered, a message would appear:
According to national guidelines, troponin is the preferred biomarker for detecting MIs. CK and CK-MB are only appropriate when troponin levels are unavailable.
After the intervention was in place for 12 months, there were tremendous results (which will be published in a forthcoming paper by Drs. Trost and Larochelle). Their intervention led to a reduction in unnecessary testing, and they reported no harm was done to patients.
This case reveals the power of order sets that may not be as up-to-date as the latest evidence. In conversations with the faculty, they also pointed out how physicians have come to rely more on medical tests and procedures, and less on their clinical judgment. It makes me wonder how many hospitals routinely order EKGs and chest x-rays for outpatient surgery or prior to admission to specified units.
Another very important feature of the project is that it involves practicing physicians, residents and medical students. There have been many calls for increased focus on stewardship in training of physicians and other health care professionals – this grantee made that part of their efforts.
During the presentation, one slide in particular caught my attention as an important challenge ahead for the Choosing Wisely® campaign. It was titled Major Challenge for the Climb: Convincing Doctors This is the Right Thing to Do.
The slide reported on a Medscape study on physician compensation in 2012 which asked “will you reduce testing to contain costs?” Physicians said “no” for a number of reasons, including:
- medical liability (24%);
- guidelines were not in the best interest of patients (43%), and;
- because of the effect on income (7%).
But these discouraging survey results didn’t deter Drs. Trost and Larochelle, who summarized their talk by saying, “Cost aside (referring to the saving derived), this is the right thing to do for patients.”
At that moment, I knew that medical professionalism could trump all other considerations. Professionalism reigned in the halls of Johns Hopkins Bayview Medical Center above all.
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