Pugel Scott, Stallworth John L, Pugh Leslie B, Terrell Carlee, Bailey Zuwere, Gramling Thomas, Ward Helen
Jt Comm J Qual Patient Saf. 2018 Dec;44(12):699-707. doi: 10.1016/j.jcjq.2018.05.010.
Scant evidence exists of effective Choosing Wisely® initiatives, which are intended to reduce the use of unnecessary care. In 2013 substantial variations existed at Kaiser Permanente Georgia in the frequency of nonbeneficial services in ambulatory care. A Choosing Wisely campaign was implemented across 25 medical offices serving approximately 300,000 members.
The initiative was designed to reduce the use of complete blood counts (CBCs) and electrocardiograms (EKGs) as routine screening tests in physical examination visits, age-inappropriate dual-energy x-ray absorptiometry (DEXA) scans, and imaging for uncomplicated headache. The change management package consisted of (1) guideline selection by clinical leaders, (2) continuing medical education for clinicians and training and education for clinic staff and advice nurses, (3) an internal and external communication plan, and (4) monthly reports.
Between January 2013 and December 2016, CBC use as a routine screening test decreased by 39.5 percentage points (95% confidence interval [CI] = 39.0-40.0)-from an average of 42.7% to 3.2%; EKG use as a routine screening test decreased by 15.5 percentage points (95% CI = 15.1-15.8)-from an average of 15.9% to 0.3%; inappropriate DEXA scan use decreased by 23.4 percentage points (95% CI = 22.5-24.5)-from an average of 25.4% to 2.0%; and imaging for uncomplicated headache decreased by 3.9 percentage points (95% CI = 3.3-4.6)-from an average of 10.8% to 6.9%. All decreases were statistically significant (p < 0.05) and were largely sustained after monthly reports ended.
Sustained reductions in nonbeneficial services in ambulatory care followed implementation of a comprehensive change management package.
关于有效的“明智选择”倡议的证据很少，该倡议旨在减少不必要医疗服务的使用。2013年，佐治亚州凯撒医疗集团门诊护理中无益服务的频率存在很大差异。一项“明智选择”运动在25个医疗办公室开展，服务约30万名会员。
该倡议旨在减少在体检就诊时将全血细胞计数（CBC）和心电图（EKG）作为常规筛查测试的使用、不适合年龄的双能X线吸收法（DEXA）扫描以及对无并发症头痛进行成像检查。变革管理方案包括：（1）临床负责人选择指南；（2）为临床医生提供继续医学教育，为诊所工作人员和咨询护士提供培训与教育；（3）内部和外部沟通计划；（4）月度报告。
在2013年1月至2016年12月期间，作为常规筛查测试的CBC使用量下降了39.5个百分点（95%置信区间[CI]=39.0 - 40.0），从平均42.7%降至3.2%；作为常规筛查测试的EKG使用量下降了15.5个百分点（95%CI = 15.1 - 15.8），从平均15.9%降至0.3%；不适当的DEXA扫描使用量下降了23.4个百分点（95%CI = 22.5 - 24.5），从平均25.4%降至2.0%；对无并发症头痛进行成像检查的使用量下降了3.9个百分点（95%CI = 3.3 - 4.6），从平均10.8%降至6.9%。所有下降均具有统计学意义（p < 0.05），且在月度报告结束后基本保持稳定。
实施全面的变革管理方案后，门诊护理中无益服务持续减少。
