Low-value care is such a pervasive problem, ABIM developed the Choosing Wisely initiative. However, Choosing Wisely is, unfortunately, a disengaged and toothless activity. And it hasn’t worked.
But, as this study shows, you can eliminate unnecessary care with a more proactive and involved approach.
This is a quality improvement collaborative across 21 hospitals aimed at reducing the use of unnecessary or ineffective care relating to bronchiolitis. As we’ve seen time and time again, if anything works at all for bronchiolitis, the ambiguity over its effectiveness probably means the effect size is clinically meaningless. To this end, these hospitals banded together to deploy a QI program targeting reductions in bronchodilator use, steroid use, chest radiography, and other process measures. Across all measures, the pre- and post-intervention measures demonstrated pooled meaningful and statistically significant improvement. Bronchodilator use dropped from 46.2% to 32.7%, steroids from 10.9% to 2.2%, and CXRs from 12% to 6.7%. A secondary effect of these interventions was a reduction in length of stay by 5 hours, from 49.6 to 44.6.
Success!
Of course, the QI intervention did not have the same effect at all participating hospitals. Some, clearly, were on the ball, and almost entirely eliminated some unnecessary care (steroids). Others, however, had no change from baseline, or, even, an increase – like two hospitals demonstrating 150%+ increase in bronchodilator use, and three hospitals with 100%+ increases in CXR use. It would be interesting to see some qualitative analysis regarding the lack of improvement at certain hospitals.
But, in general, widespread improvement in unnecessary care can be realized. In contrast to Choosing Wisely, it requires motivated agents of change and constant feedback. The Choosing Wisely lists and their elements, unfortunately, seem adrift.
“A Multicenter Collaborative to Reduce Unnecessary Care in Inpatient Bronchiolitis”