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Following Choosing Wisely With Real-Time Support Tools Trimmed Hospital Stays, Cost in AJMC® Study


Healthcare savings foreseen with adoption of electronic health records have fallen short of expectations but adding clinical decision support tools could change that. A new study in The American Journal of Managed Care® shows how Cedars-Sinai Health System achieved better care and savings by following Choosing Wisely recommendations.

Following alerts to adhere to Choosing Wisely recommendations led to shorter hospital stays, fewer complications and 30-day readmissions, and lower costs, according to a new study in The American Journal of Managed Care® (AJMC®).

The study showed how integrating Choosing Wisely recommendations into real-time decision support tools improved care in the Cedars-Sinai Health System in California. The study compared how patients fared when providers followed the alerts with outcomes when alerts were ignored.

The Cedars-Sinai research team, in its joint analysis with Optum Advisory Services, found:

  • Total costs for patient encounters rose 7.3% when providers failed to follow Choosing Wisely alerts compared with when they accepted recommendations.
  • Length of stay was 6.2% higher when providers ignored Choosing Wisely.
  • Failing to follow Choosing Wisely increased the likelihood of readmission within 30 days (odds ratio [OR], 1.14; 95% CI, 0.998-1.31 for nonadherent vs adherent encounters).
  • Failing to follow Choosing Wisely raised the risk of complications (OR, 1.29; 95% CI, 1.04-1.61 for nonadherent vs adherent encounters).

“Despite the publication of myriad evidence-based guidelines, providers continue to order tests, procedures, and medications for patients that may be not only be inappropriate, but sometimes also lead to worse health outcomes and higher costs for patients and third-party payers, such as employers, insurance carriers, Medicare, and Medicaid,” said study co-author John Kontor, MD, of The Advisory Board Company.

The findings suggest that adding alerts is the key to realizing the savings predicted from widespread adoption of electronic health records; however, the authors say they could not pinpoint a cause-and-effect relationship between the clinical outcomes and savings, so more research is needed.

“We recommend that health systems consider real-time [clinical decision support] interventions as a method to encourage improved adoption of Choosing Wisely and other evidence-based guidelines,” wrote the authors, led by Optum’s Andrew M. Heekin, PhD.

“Incorporating decision support tools into electronic health records has consistently been among the top methods used in multicomponent interventions by the Choosing Wisely grant projects that successfully reduced unnecessary care,” said Kelly Rand, Program Manager for the Choosing Wisely campaign. “Best practice alerts, SmartSets and other CDS, when strategically integrated into clinical workflows, help improve decision making.”

In an accompanying editorial, AJMC® co-editor-in chief A. Mark Fendrick, MD, and Michael Budros, MPH, MPP, wrote, “This study adds to promising evidence that [clinical decision support] assists clinicians in making value-based clinical decisions and reducing the use of care that is not clinically indicated.”

Fendrick and Budros noted that only 6 percent of the Cedars-Sinai providers followed all the alerts, so “there is significantly more work to be done.”

About The American Journal of Managed Care®:

The American Journal of Managed Care® (AJMC®) is a peer-reviewed, MEDLINE-indexed journal that keeps readers on the forefront of health policy by publishing research relevant to industry decision makers as they work to promote the efficient delivery of high-quality care. AJMC.com is the essential website for managed care professionals, distributing industry updates daily to leading stakeholders. Other titles in the AJMC® family include The American Journal of Accountable Care®, and two evidence-based series, Evidence-Based Oncologyand Evidence-Based Diabetes Management. These comprehensive offerings bring together stakeholder views from payers, providers, policymakers and other industry leaders in managed care. To order reprints of articles appearing in AJMC® publications, please contact Jeff Prescott at 609-716-7777, ext. 331.

About ABIM Foundation

The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. This is achieved by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policy makers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org, connect on Facebook or follow on Twitter.

About Choosing Wisely®

First announced in December 2011, Choosing Wisely® is part of a multi-year effort led by the ABIM Foundation to support and engage physicians in being better stewards of finite health care resources. Participating specialty societies are working with the ABIM Foundation to share the lists widely with their members and convene discussions about the physician’s role in helping patients make wise choices. Learn more at http://www.choosingwisely.org/.


AJMC® Media:

Theresa Burek, 609-716-7777



Surabhi Verma


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