Avoid defensive medicine via “baked in” best practice guidelines

Two recent studies with findings summarized in JAMA caught our eye because they provide interesting proof points on the value and need for “operationalizing” best practice guidelines as a hedge against habit and, sometimes, fear.

Both studies suggest that physicians may have a hard time being judges of the reasoning behind their own decision-making. And that old habits die hard!

In the study summarized in the JAMA Research Letter “The Cost of Defensive Medicine on 3 Hospital Medicine Services” (JAMA Online, Sept. 15, 2014), researchers assessed the “defensiveness” of the ordered procedures at several Massachusetts-area hospitals.

What struck us was the observation by study authors (quoted by Modern Healthcare, in “Doctors order unnecessary tests without even realizing it”) that doctors might think they’re just following the standard of care and may not be cognizant of the “defensive” nature of their decisions.

Per lead author Dr. Michael Rothberg, “Some people might say it’s defensive, and other people might think it’s the standard of care. “There’s really more of a culture about how people treat a particular problem, and many may not recognize it as being defensive. […] Clear communication about evidence-based guidelines and tort reform that would protect clinicians when they follow those guidelines would help reduce providers’ fear and improve patient care.”

Another Research Letter in JAMA has a related theme: How to prevent overuse of inappropriate procedures.  (“Altering Overuse of Cardiac Telemetry in Non–Intensive Care Unit Settings by Hardwiring the Use of American Heart Association Guidelines,” JAMA Online, Sept. 22, 2014.)

“Various efforts to reduce the perceived overuse of cardiac telemetry at Christiana Care Health System, a 1100-bed tertiary care system, were unsuccessful. In August 2012 we convened a team to increase the appropriate use of non-ICU cardiac telemetry through the integration of AHA guidelines into our electronic ordering system.”

Results were dramatic.

“After the changes, the researchers found the hospital group’s mean daily number of non-ICU patients monitored with telemetry fell by 70%, from 357.5 to 109.1, while the mean daily cost for delivering non-ICU telemetry also fell by 70%, from $18,971 to $5,772. The changes had no negative effect on patient care; mortality rates at the hospitals remained stable, as did the number of “code blue” emergency calls to resuscitate patients.”  (“Hospitals Cut Costs by Getting Doctors to Stick to Guidelines,” Wall Street Journal, Sept. 22, 2014)

Our takeaway: Operationalizing best practice guidelines by incorporating those guidelines in software is a valuable tool for changing entrenched behavior.

P.S. QPID Health helps providers address utilization issues with our Q-Guide solution. Q-Guide counterbalances the adverse effect of accidental, “defensively-motivated” procedures and habits, which are brought to light in the JAMA studies.

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