Choosing Wisely at Austin Health Lessons Learnt in An Australian Health Service

Background Austin Health is tertiary academic public health service, which services its local catchment and also provides a number of state wide services. Austin operates 911 beds and employs over 8000 staff across three sites The Choosing Wisely project at Austin Health was funded through the 2016/17 BCV Innovation Fund and delivered with support from NPS MedicineWise (Choosing Wisely Australia) and Eastern Health (NUTS program)

Choosing Wisely at Austin Health Objectives: Engage consumers, clinicians and hospital staff in the concept of “More is not always better” when it comes to medical tests, treatments and procedures Empower health professionals to question what care is truly needed Engender support for the project among key health services and non-medical stakeholders Engage with other health services and healthcare providers in supporting the initiative and encourage implementation of the recommendations Support clinicians to understand and engage in high quality evidence based practice Encourage consumers to engage in conversations about their care with their healthcare providers

Project Governance Project Manager – 0.8 EFT Four clinical leads (consultants) – 0.2 EFT each Emergency Department / Quality & Audit Medical Oncology Anaesthetics / Pain Services Gastroenterology / Medical Education Multidisciplinary steering committee – Meeting monthly Junior medical staff committee - Meeting bi-monthly Additional resources: Finance Department Business Intelligence Unit Clinical Informatics Team Communications Team

Project Development

Topic Selection Core topic areas Coagulation Studies Four key areas of behaviour change strategies undertaken for each topic area Urine Cultures De-prescribing Opioids PPIs

Topic Selection Core topic areas Coagulation Studies Four key areas of behaviour change strategies undertaken for each topic area Urine Cultures De-prescribing Opioids PPIs

Topic Selection Secondary areas Febrile neutropenia management Activities independently undertaken by the Choosing Wisely Clinical Leads with support from project team CRP Ordering in ED Lower back imaging in ED Colonoscopy preparation End of Life Care CT Imaging for Low Risk PE

Problem Identification Coagulation Studies Problem Identification Anecdotal evidence from senior clinicians that there is a high volume of Coagulation Studies ordered inappropriately WHY? Coags = INR, APTT, Fibrinogen and PT as a group Clinicians ordering coags when only INR needed Coags being on the list of high frequency tests on electronic ordering system What are the financial benefits realised during this time?

Baseline Data Coagulation Studies What are the financial benefits realised during this time?

Behaviour Change Strategies Coagulation Studies Behaviour Change Strategies Quality & Audit Hospital wide audit of test ordering by clinical group Pre- and post-intervention audit and feedback Regression modelling of factors associated with multiple test ordering

Behaviour Change Strategies Coagulation Studies Behaviour Change Strategies Quality & Audit Hospital wide audit of test ordering by clinical group Pre- and post-intervention audit and feedback Regression modelling of factors associated with multiple test ordering Policy & Guidelines Development of new pathology guidelines Development of Decision Support Tool Linking of guideline document to online ordering system

Behaviour Change Strategies Coagulation Studies Behaviour Change Strategies Quality & Audit Hospital wide audit of test ordering by clinical group Pre- and post-intervention audit and feedback Regression modelling of factors associated with multiple test ordering Education & Peer Support Lunch time education sessions Grand round presentations Presentations to external groups Intranet information campaigns Links to publications and resources Policy & Guidelines Development of new pathology guidelines Development of Decision Support Tool Linking of guideline document to online ordering system

Behaviour Change Strategies Coagulation Studies Behaviour Change Strategies Quality & Audit Hospital wide audit of test ordering by clinical group Pre- and post-intervention audit and feedback Regression modelling of factors associated with multiple test ordering Education & Peer Support Lunch time education sessions Grand round presentations Presentations to external groups Intranet information campaigns Links to publications and resources Policy & Guidelines Development of new pathology guidelines Development of Decision Support Tool Linking of guideline document to online ordering system Informatics Pop-up messaging with the ordering of Coagulation Studies on CERNER Removal of Coags group from list of Common Tests Splitting of Coags group

Coagulation Studies Decision Support Tool

Coagulation Studies Feedback Reports

Promotional Strategies Coagulation Studies Promotional Strategies

Results – ED Coagulation Studies What are the financial benefits realised during this time?

Results – Hospital Wide Coagulation Studies Results – Hospital Wide What are the financial benefits realised during this time?

Results Coagulation Studies Pre-intervention Post-intervention Volume of tests across whole hospital Weekly mean = 686.18 Weekly mean = 552.22 ↓ p<0.05 Volume of tests in ED Weekly mean = 119.11 Weekly mean = 49.39 Volume of tests per patient whole hospital 0.27 0.16 ↓ 39.9% Volume of tests per patient in ED 0.07 0.01 ↓ 81.4% Pathology costs per patient whole hospital (inpatient and ED) ↓ $75 per patient episode Total potential savings of $191,025 Audit: Indications for coagulation study ordering ↓ 4 out 5 audit units reported a decrease in orders with no indication What are the financial benefits realised during this time?

High volume coagulation study ordering Coagulation Studies Results High volume coagulation study ordering Number of admissions Number of prescribers Number of wards Average variation of INR from normal range Average variation of APTT from normal range Average variation of Fibrinogen from normal range Average variation of PT from normal range What are the financial benefits realised during this time?

High volume coagulation study ordering Coagulation Studies Results High volume coagulation study ordering Number of admissions Number of prescribers Number of wards Average variation of INR from normal range Average variation of APTT from normal range Average variation of Fibrinogen from normal range Average variation of PT from normal range For every increase in prescriber, 5 additional coagulation studies were ordered. What are the financial benefits realised during this time?

Problem Identification Urine Cultures Problem Identification High volume of urine cultures being processed in the microbiology labs in addition to High volume of repeat tests Poor reporting of indications for why urine culture has been ordered High rate of contaminated samples Inconsistent urine sample collection techniques What are the financial benefits realised during this time?

Behaviour Change Strategies Urine Cultures Behaviour Change Strategies Quality & Audit Hospital wide audit of test ordering by clinical group Pre- and post-intervention audit and feedback Personalised ED clinician feedback

Behaviour Change Strategies Urine Cultures Behaviour Change Strategies Quality & Audit Hospital wide audit of test ordering by clinical group Pre- and post-intervention audit and feedback Personalised ED clinician feedback Policy & Guidelines Development of pathology & procedure guidelines Development of Decision Support Tool Linking of guideline document to online ordering system

Behaviour Change Strategies Urine Cultures Behaviour Change Strategies Quality & Audit Hospital wide audit of test ordering by clinical group Pre- and post-intervention audit and feedback Personalised ED clinician feedback Education & Peer Support Lunch time education sessions Hub campaigns Links to literature via Hub page ATLAS Learning module Educational posters in ED Policy & Guidelines Development of pathology & procedure guidelines Development of Decision Support Tool Linking of guideline document to online ordering system

Behaviour Change Strategies Urine Cultures Behaviour Change Strategies Quality & Audit Hospital wide audit of test ordering by clinical group Pre- and post-intervention audit and feedback Personalised ED clinician feedback Education & Peer Support Lunch time education sessions Hub campaigns Links to literature via Hub page ATLAS Learning module Educational posters in ED Informatics Pop-up messaging with the ordering of Urine Cultures on CERNER Link to new guideline and flowchart upon ordering of Urine Cultures Policy & Guidelines Development of pathology & procedure guidelines Development of Decision Support Tool Linking of guideline document to online ordering system

Results – Hospital Wide Urine Cultures Results – Hospital Wide

Urine Cultures Results - ED

Promotional Strategies Urine Cultures Promotional Strategies

Urine Cultures Decision Support Tool

Results Results Urine Cultures Pre-intervention Post-intervention Volume of tests across whole hospital Weekly mean = 340.77 Weekly mean = 250 ↓ p<0.05 Volume of tests in ED Weekly mean = 142.15 Weekly mean = 87.69 Volume of tests per patient whole hospital 0.09 0.06 ↓ 32.8% Volume of tests per patient in ED 0.08 0.04 ↓ 45.8% Audit: Indications for coagulation study ordering ↓ 2 out 5 audit units reported a decrease in orders with no indication

CRP Results - ED What are the financial benefits realised during this time?

Results – Hospital Wide CRP Results – Hospital Wide What are the financial benefits realised during this time?

Organisation-wide Activities Updated governance and procedures for Care Set and Order Set development Nursing, Medical and Consumer surveys Monthly newsletters Dedicated intranet page MDRP Student Projects – Developing adaptive learning platforms GP newsletter articles and meeting presentations Creating links with new projects Discharging Wisely Testing Wisely – Frequency of discordance HER2 results Library strategy

Organisation-wide Activities 63% of surveyed staff were aware of Choosing Wisely and the 5 Questions for Consumers 78% believe Choosing Wisely to be a worthwhile investment 65% would feel comfortable encouraging the use of the 5 Questions 84% had heard Choosing Wisely discussed at hospital meetings Top 3 Enablers for Conversation between Patient and Clinicians 1. More Time 2. More information 3. Clinician Skill 75% of consumers felt that the 5 Questions for consumers had utility in the consultation space 84% felt comfortable asking their health professionals about necessary care 89% of consumers had their last test at the hospital initiated by the clinician 84% would use the Urine Culture poster to guide them on the correct way to collect a sample Top 3 Barriers to Asking their Clinician Questions 1. Insufficient appointment time 2. Trust the doctor‘s expertise 3. Worried about taking up doctor time Library strategy

Sustainability Strategies Library strategy

Sustainability Strategies Library strategy

Lessons Learnt Multi-disciplinary engagement and motivation Culture change Making successful changes part of everyday practice Importance of robust data systems Ongoing monitoring and feedback Active engagement with established systems: Intern orientation and education curriculum Research Week QI activities across the hospital

Next steps State-wide leadership through the Choosing Wisely Scaling Collaboration 2018-2019 EOI process will commence early 2018 for 10 health services to join the collaborative Focus of the collaborative will be reducing unnecessary pathology and imaging tests through empowering and guiding health services in the principles of Choosing Wisely