Details of the High Value Care projects, the measured baseline, implementation strategy and results as available
| High value care projects | Baseline measurement | Implementation strategy | Results |
|---|---|---|---|
| Completed projects | |||
| Do not measure creatinine on a patient receiving scheduled dialysis Specialty: Nephrology Reason: Unnecessary | Date: July 2010 to July 2012 (2 years) Target Population: Inpatients with ESRD on HD who had creatinine checked. Baseline: Cr.: 957 per 1000 patient days | Education of medicine resident trainees. Discussion at resident quality council. EHR BPA to alert when BUN or Cr. is ordered on patients with ESRD | 72% reduction in Cr. performed on target population. July 2013–July 2014 Creatinine: 270 per 1000 patient days |
| Do not perform a DXA scan on a woman less than 65 years old without clinical risk factors for early osteoporosis. Specialty: Rheumatology Reason: Non-indicated | Date: July 2008 to July 2012 (4 years) Target population: Patients who underwent a DXA who were <65 years without clinical risk factors Baseline: 10.3% of total DXA performed were on target population | Letter to all ordering providers from the director of the osteoporosis centre outlining early osteoporosis clinical risk factors. Redesign of the electronic and paper order to allow for decision support and documentation of clinical risk factors if <65 years old | 75% reduction in target population in 1 year. Over 90% reduction by year 2. No significant change in volume of DXA performed. This is attributed to a decrease in volume in those <65 years and an increase in those >65 years old and improved documentation of risk factors for those less than 65 years old |
| Do not perform routine daily chest X-rays on intubated patients Specialty: Critical care Reason: Low value, does not change patient management | Date: August 2011 to October 2012 Target population: Mechanically ventilated medical patients Included days: Non-1st day of intubation and non-procedure dates Baseline: 866 CXRs performed per 1000 intubated days. Included days, exclude the 1st day of intubation or a procedural day | Discussion and reporting on MICU rounds, morning report. Removed daily CXR as an option on the ICU admission and intubation order sets. Added question on ICU rounding checklist regarding a CXR the next day | Within 4 months, there was a decrease of 71% to a low of 250 CXRs performed per 1000 included intubated days |
| Do not repeat a positive hepatitis A or C antibody. Specialty: Gastroenterology Reason: Redundant testing | Date: January 2010 to September 2013 Target population: All patients who underwent a hepatitis A or C antibody Baseline: 150 repeat positive hepatitis A antibodies on 130 patients. 138 repeat positive hepatitis C antibodies in 106 patients | EHR-based BPA which alerts if the patient has had a prior positive hepatitis A or hepatitis C antibody. The BPA provides the result and date of prior test | 1 October 2014 to 30 September 2015: Per cent of positive tests with a repeat ordered Hepatitis A: 13.2% (84 tests) increase from 77 during the prior year period Hepatitis C: 7.69% (18 tests) decrease from 52 in prior year period. The hepatitis C results are favourable, however, we are currently evaluating why hepatitis A increased |
| Do not perform PET or bone scan imaging on asymptomatic women with stage I or stage II breast cancer Specialty: Oncology Reason: Non-indicated | Date: October 2012 to October 2013 (1 year) Target population: Women with new diagnosis of stage I or stage II breast cancer treated with curative intent Baseline: 92 total cases of breast cancer, 39 stage I/II. Further staging imaging performed on 34 patients which did not meet ASCO criteria, 0% of scans found metastatic disease, 11.1% false-positive rate | Discussion within the division of Oncology and development of institution-specific guidelines. Training on using discrete data to stage patients within the EHR | We are currently unable to identify the target population electronically. Staging data is not discrete within our EHR. There is a separate quality initiative in the cancer centre to move staging into discreet data. Because we are unable to track, the project has been moved to complete |
| Ongoing projects | |||
| Do not repeat a positive ANA Specialty: Rheumatology Reason: Redundant testing | Date: June 2011 to June 2013 (2 years) Target population: Patients who had a prior positive ANA in the study period Baseline: 323 repeat positive ANAs on 262 patients over 2 years | Identified barriers: Initially unable to create an EHR-based warning but new added functionality to the EHR allowed for the creation of a BPA warning that a prior ANA was positive, the value and date of the test | Status: Currently collecting data since the BPA was implemented |
| Do not perform an echocardiogram in the setting of heart failure if one has been conducted in the past year and it will likely not change management. Specialty: Cardiology Reason: Redundant testing | Date: Jan 2011 to Jan 2014 Target population: All inpatients who received more than one limited or full TTE in the past year Baseline 11 153 TTE's were performed. 18.2% were repeated within 365 days | Medicine resident trainees educated on the indications for a repeat echocardiogram and the difference between full and limited studies. Electronic prompt developed for EHR which alerts the user if a full TTE has been performed in the past year and recommends re-evaluation and/or a limited echocardiogram | Unanticipated results: In the first 12 months there was no significant change in ordering practices. The team is reconvening and evaluating a change to the system intervention or continued education or ordering providers |
| Projects determined to be unnecessary | |||
| Do not perform elective screening colonoscopy on patients older than 75 years Specialty: Gastroenterology Reason: Non-indicated | Date: October 2010 to October 2012 (2 years) Target population: Patients 76 years or older who underwent screening colonoscopy Baseline: Age >75 years: 78 performed, 49% (38) of these were on patients whose age was 76 years. 2.08% of total screenings | Rate less than project champion expected. Did not elect to move forwards with formal project, however, the gastroenterologists have begun screening patients 80+ years old and having conversations with the ordering providers | The number of patients 85+ years, screened since project, dropped from 3 to 1 over 2 years. No significant change in other screening rates. |
ANA, antinuclear antibody; BPA, best practice advisory; DXA, dual-energy X-ray absorptiometry; EHR, Electronic Health Record; ESRD, end stage renal disease; HD, haemodialysis; ICU, intensive care unit; MICU, medical ICU; PET, positron emission tomography; TTE, transthoracic echocardiogram.