Choosing Wisely Manitoba Early Adopters Presented by Dr. Eric Bohm, MD, FRCS Director Health System Platform, CHI Mr. Jim Slater, MLT(ART), BSc, MBA Chief Executive Officer, DSM
Core Objectives of CWM Improved health outcomes Improved patient and provider experience Improved health system efficiencies Improved health system sustainability
Choosing Wisely Manitoba CWM has engaged with: Provincial Medical Leadership Council College of Physicians and Surgeons Manitoba Manitoba College of Family Physicians Doctors Manitoba Centre for Health Care Innovation Manitoba Centre for Health Policy University of Manitoba, Faculty of Health Sciences College of Pharmacists of Manitoba and many others Focuses on opportunities specific to Manitoba.
By physicians, for physicians As a key stakeholder and point of contact for patients, physicians like you play an important role in improving appropriate diagnostic testing and treatment.
Physician Engagement and Leadership Undergraduate Programs Postgraduate and Resident Programs Continuing Professional Development Programs Health System Transformation Improving Physician Engagement Developing Physician Leadership
Physician Role Conflict? Doing best for the patient in your office Ensuring the system has sustainable resources for the next patients that come to your office
Communications Two-Pronged Approach: Brand Strategy CWM General Awareness Priority Area(s) Communications: Vitamin D Preoperative
MCFP Survey Results 175 responses from 1,200 members 14% response rate 67% of respondents have heard of Choosing Wisely 26% of respondents have already adopted some of its principles into their practice 82% agree that Choosing Wisely can improve physician and patient conversations about unnecessary tests, treatments & procedures 73% agree that Choosing Wisely can improve the efficiency of Manitoba s health care system.
MCFP Survey: What Physicians Told Us: Develop a Public education strategy Develop a strategy to support physicians Provide branded materials for patients Competing with Dr. Oz and Dr. Google can make it difficult for patients to accept Explaining/rationalizing to patients will be a hurdle Unless all docs adopt CWM concepts, patients will go to other docs who will provide desired tests
Launching the Choosing Wisely Manitoba Initiative Info sheet sent to MCFP and Physicians across Manitoba. Following-up and Engaging physicians.
Clinical Practice Change Establishing a standard to communicate Clinical Practice Changes
Choosing Wisely Manitoba Projects Why Diagnostics?
Barriers to guideline adoption GL are confusing Too time consuming to follow Forms do not support GL Liability issues Do not agree with GL Unaware of GL Patient requests additional testing Easier to order as per the surgeons request Easier to order to prevent surgery rescheduling
Growth in Volume of Physician Services
Bone Marrow and Microarray Volume Growth 1200 Specialty Testing Volume Growth 1000 Test Volume 800 600 400 Bone Marrrows Microarray 200 0 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15
Bone Marrow and Microarray Cost Growth 600000 Specialty Testing Cost Growth 500000 400000 Cost 300000 200000 Bone Marrrows Microarray 100000 0 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15
Preoperative Diagnostic testing Test Not indictated and Ordered Test Not indictated and Ordered (Phase 3 audit) Test Not indictated and Ordered (annual estimate) Test Name $ / individual test Annual $ Estimate % of $ Chest X Ray $ 28.55 66 $ 1,884.30 15,619 $ 445,916.11 21% Liver Function Tests $ 24.30 58 $ 1,409.40 13,726 $ 333,531.90 15% ECG $ 22.15 56 $ 1,240.40 13,252 $ 293,538.36 14% Electrolytes $ 19.00 62 $ 1,178.00 14,672 $ 278,771.52 13% TSH $ 19.30 30 $ 579.00 7,099 $ 137,019.28 6% PTT $ 9.12 62 $ 565.44 14,672 $ 133,810.33 6% Creatinine $ 8.65 63 $ 544.95 14,909 $ 128,961.41 6% INR $ 6.45 73 $ 470.85 17,275 $ 111,425.78 5% Glucose $ 4.95 88 $ 435.60 20,825 $ 103,083.93 5% CBC $ 5.95 73 $ 434.35 17,275 $ 102,788.12 5% Iron indices $ 16.15 20 $ 323.00 4,733 $ 76,437.35 4% Urinalysis $ 4.90 25 $ 122.50 5,916 $ 28,989.40 1% Total 676 $ 9,187.79 159,974 $ 2,174,273.49 100% 62% 4 tests account for 62% of the dollars spent on tests not indicated and ordered
Increasing Volumes vs Status-Quo Funding
Labs need to be more efficient!! The more E fficient we are the more $ we can reallocate to increasing volumes and new tests The more E ffective you are, the more $ we can reallocate to increasing volumes and new tests
Benefits Realization KPI Indicator/Description Baseline Original Target Result Achieved Comments 1. Reduction in red cell discards in rural Manitoba hospitals 2. Reduce crossmatch to transfusion ratio 3. Reduce the need for red cell and platelet products to be returned to the CBS Crossmatch for rei 4. Reduce STAT response times 26% 8% <5% 2.5:1 2:1 1.1:1 50% 20% 1% 60 minutes 15 minutes 15 minutes Resulting in annual saving of 450 RBC Increases red cell product utilization efficiency Avoidance of 1,000 potential RBC discards When in-date crossmatch samples available
Most preoperative lab tests are unnecessary, inefficient and potentially harmful Preoperative lab test No high level evidence of benefit Differing expectations between anesthesia providers Abnormal result False positive results Unnecessary delays in surgery Patient inconvenience Substantial cost Adverse outcomes Tests ordered FOR anesthesia BY others Clinically trivial abnormalities Change in management Cancellation/Delay insurance Unnecessary repeat and confirmative testing No change in management Prevention of postoperative complications
Contemporary preoperative care is multidisciplinary Primary care Surgeon Primary care PAC* SURGERY *PAC: Pre-anesthetic clinic (Anesthesiology)
Project objectives Design and implement a PROVINCIAL preoperative laboratory testing guideline to improve: Standardization of expectations between sites Communication between providers Efficiency in the use of preoperative testing... and evaluate guideline effectiveness
Our Guideline: 8.5 11
Guideline implementation: November 2010 to March 2011 Province wide: Presentations at provincial primary care conference, Grand rounds, standards committees and other information programs Distribution to each region s administration for dissemination within that region In addition, within the WRHA: Delivery by mail to all end users
Guideline evaluation: Audit design Retrospective chart reviews Guideline population elective, adult surgical patients All performed by one experienced auditor. Each audit a random sample typical week within the Winnipeg RHA stratified by site and surgical specialty Ethics board approval obtained to re-analyze quality assurance data collected in serial audits.
Audit results Nov/10 Baseline established Mar/11 Guideline implemented Sept/11 6 month audit (14.6% reduction!) May/13 2 year audit (rebound to above baseline)
Project Revisited Goal to ensure all Manitobans receive the necessary and appropriate preoperative diagnostic testing for elective surgeries through the sustainable implementation of a standardized, evidence informed clinical practice guideline
Project Framework Stakeholder Consultation Literature Review Process Mapping Barriers and Facilitators Identified Engagement with key stakeholders Strategy development Project Team Implement Evaluate Learn
Where are the unnecessary tests? 3 Specialties account for 70% of unnecessary tests: Ophthalmology surgery (31% of all unnecessary tests) Orthopeadic surgery (23%) General surgery (17%) Note: Phase 3 Audit
Estimated Value of Unnecessary Tests
Ophthalmology Cataracts ~10,000 cataract procedures annually no preoperative lab test routinely required Standardized, unique History & Physical form used for cataract patients Standardized processes utilized by surgeons who operate at Misericordia Health Centre
Orthopedic Surgery 2 elective procedures account for 50% of the elective volume: Hip and Knee replacements Non standardized processes Different cover letters cueing unnecessary tests Some surgeons order tests, others send to PCP Multiple surgeons / offices
General Surgery 3 procedures = 50% of elective surgical volumes - Diagnostic / Therapeutic Intervention - large intestine (38%) - Therapeutic intervention - muscles chest & abdomen (12%) Limited awareness of the guidelines General surgeons order 55-77% of UTs Current ordering processes may not be amendable to standardization
What are the issues? Guidelines time-consuming to interpret Surgeon cover letters / forms do not support the guidelines Liability concerns Do not agree or unaware of guidelines Easier to order unnecessary tests than cause potential delay
Implementation Strategies More user friendly H&P forms / Specialist letters More user friendly Preoperative testing grid Physician Engagement EMR enhancements Process Flow Changes Communication / Education strategy Preoperative App Physician level Feedback
Purpose of the Evaluation Understand what is working / not working well Provide feedback and support for decision-making Understand the impact of strategies implemented on unnecessary preoperative diagnostic testing
Components of the Evaluation Developmental Evaluation Quantitative Document review Qualitative and surveys Chart Audit (ophthalmology and orthopedics) Administrative Data (all specialties) Project documents Interviews, consultations or surveys with: Project team members and stakeholders Users of forms and other tools developed Evaluation Platform
Evaluation Questions- Summary Are revised documents being used with all patients & by all providers (as appropriate)? Do stakeholders consider changes to be an improvement? Can the impact of each strategy be identified? What worked well and what could have been improved related to developing and implementing the new forms, documents & processes? Have any reductions in ordering unnecessary tests been maintained?
Vitamin D Testing 60,000 Vitamin D Testing 50,000 40,000 30,000 20,000 10,000-2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2015 volumes are estimated Vitamin D testing has increased by approx. 1,000% since 2006 Approx. $800,000 annually on unnecessary Vit D tests
Vitamin D CW Recommendation Don t perform population based screening for 25-OH-Vitamin D deficiency. Many intervention strategies were assessed / discussed in Manitoba Media Campaign educating patients and physicians Targeted communication to ordering physicians De-enlist Vitamin D testing New ordering forms Restricting ordering to certain providers
Intervention Strategy All Medically necessary 25-hydroxy vitamin D testing will be supported Intervention support Engagement with key stakeholders Docs Mb and the College of Physicians and Surgeons Change current process Communication plan New lab requisition form
Communications Plan Resource & Tool Kit for Family Physicians Call to Action letter from CWM Leaders Diagnostic Guidelines & Recommendations Patient Conversation Sheets Posters Patient hand-out/pamphlet/tear-off Subscription form to CWM mailing list Re-order Form CWM Promo Items (if budget allows)
Choosing Wisely Manitoba D-Dimer/Imaging for DVT and PE Imaging for lower back pain Imaging for headache and head pain Fecal occult blood test (FOBT) and many others; if we are successful in developing a robust and engaging process with physicians across MB, we will not have to do 1 project per CWC recommendation!!!
For more information http://chimb.ca/choosingwisely amota@wrha.mb.ca tmangano@dsmanitoba.ca