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The American Journal of Managed Care August 2018
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Paul Crits-Christoph, PhD; Robert Gallop, PhD; Elizabeth Noll, PhD; Aileen Rothbard, ScD; Caroline K. Diehl, BS; Mary Beth Connolly Gibbons, PhD; Robert Gross, MD, MSCE; and Karin V. Rhodes, MD, MS
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Choosing Wisely Clinical Decision Support Adherence and Associated Inpatient Outcomes
Andrew M. Heekin, PhD; John Kontor, MD; Harry C. Sax, MD; Michelle S. Keller, MPH; Anne Wellington, BA; and Scott Weingarten, MD
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Michael Budros, MPH, MPP, and A. Mark Fendrick, MD
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John F. Steiner, MD, MPH; Michael R. Shainline, MS, MBA; Jennifer Z. Dahlgren, MS; Alan Kroll, MSPT, MBA; and Stan Xu, PhD
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David Chess, MD; John J. Whitman, MBA; Diane Croll, DNP; and Richard Stefanacci, DO
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Sneha Kannan, MD; David A. Asch, MD, MBA; Gregory W. Kurtzman, BA; Steve Honeywell Jr, BS; Susan C. Day, MD, MPH; and Mitesh S. Patel, MD, MBA, MS
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Choosing Wisely Clinical Decision Support Adherence and Associated Inpatient Outcomes

Andrew M. Heekin, PhD; John Kontor, MD; Harry C. Sax, MD; Michelle S. Keller, MPH; Anne Wellington, BA; and Scott Weingarten, MD
This analysis examines the associations between adherence to Choosing Wisely recommendations embedded into clinical decision support alerts and 4 measures of resource use and quality.

A total of 26,424 encounters were included in the analysis out of a total of approximately 100,000 encounters. In 1591 (6%) of these encounters, providers adhered to all alerts (an “adherent encounter”); in the remaining 24,833 (94%) encounters, no alerts were adhered to (a “nonadherent encounter”) (Table 1). Patients in the adherent and nonadherent encounter groups were similar with respect to age (P = .32) and total diagnoses (P = .26). Additionally, both encounter groups were comparable with respect to the proportion of patients whose primary payer was Medicare (P = .94). There were significant differences in APR-DRG severity levels (P = .01), with sicker patients in the nonadherent group (a greater proportion of nonadherent patients classified at level 4, extreme). Additionally, there were differences with respect to Elixhauser index scores (P = .04), case mix index values (P = .02), gender (P = .05), and expected length of stay (P <.001) (Table 1).

With respect to outcomes, bivariate analyses indicated that patient encounters in the group in which providers did not adhere to CW recommendations had longer unadjusted actual lengths of stay (<.001) and higher complication rates (P <.001), 30-day readmission rates (P = .02), and direct costs (P <.001).

Overall, adherent encounters had significantly lower total costs, shorter lengths of stay, and lower odds of complications compared with nonadherent encounters. The coefficient of the independent variable used to determine lower odds of 30-day readmissions when the encounter is in the adherent group did not achieve significance. After adjusting for patient characteristics, nonadherent encounters also showed a 7.3% (95% CI, 3.5%-11%; P <.001) increase in total direct costs versus adherent encounters. That represents an increase of $944 for a nonadherent encounter versus an adherent encounter (Table 2).

We found a 6.2% (95% CI, 3.0%-9.4%; P <.001) increase in length of stay for nonadherent versus adherent encounters (Table 3). We found that the odds of a patient having a readmission within 30 days were 1.14 (95% CI, 0.998-1.31; P = .0503) times higher in nonadherent encounters (Table 4). The odds of a patient having complications were 1.29 (95% CI, 1.04-1.61; P = .02) times higher in nonadherent encounters (Table 5).


To our knowledge, this is the first study to evaluate the association between adherence to multiple CW guidelines delivered via CDS and changes in clinical and financial outcomes. Previous studies have established that effective CDS can impact provider behavior and contribute to improved patient outcomes for specific CDS interventions.31 This study contributes to the established body of research indicating that adherence to effective CDS alerts is associated with improved outcomes, such as length of stay,32,33 complication rates,34,35 and overall cost.36,37 Our analysis provides new evidence of the effect that a more comprehensive collection of alerts has on high-level patient and financial outcomes, including shorter length of stay (0.06 days), lower complication rates (odds ratio, 1.29), and reduced cost (7.3%) per adhered patient episode.

Our results suggest that the difference in cost savings is statistically and clinically significant. Adherent encounters resulted in approximately $944 in savings from the median encounter cost of $12,940. A previous study examined the prevalence of 28 low-value services in a large population of commercially insured adults and identified an average potential cost savings of approximately $300 for each patient who received a single low-value service.10 Our findings surpass this estimate and imply significant cost-savings opportunities through improved and broader utilization of CDS.

Our results also confirm the association between alert adherence and odds of complications as defined by AHRQ’s HCUP.18 The majority of studies do not specifically analyze the effect of CDS interventions on complication rates for patients; rather, they identify undesired outcomes, such as adverse drug events26 and mortality rates.25 Although it is plausible that the reduction in the utilization of low-value services resulting in lower inpatient lengths of stay may lead to reduced complication rates, we did not evaluate potential causation between specific complications and avoided interventions. Additional research to confirm these findings and, more specifically, to delineate the causal pathway is indicated.

Previous studies’ findings have shown a positive correlation between CDS implementation and patient length of stay.23,24 However, to our knowledge, no analyses have established a correlation between CDS content targeting unnecessary care and improved lengths of stay. Our findings demonstrate an association between adherence to guideline-based alerts and reduction in unnecessary care with shortened inpatient length of stay.

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