By coming together in small groups and discovering that their practice styles varied significantly, 832 doctors decreased their ordering of Vitamin D blood tests.
Economists are fond of saying that the only way to get anyone to change their behavior is through financial incentives, but we have discovered that there is a different motivator that works faster and easier with medical doctors: information about how they differ from their peers. It turns out that the realization that their frequency of using a certain medication or lab test is very different from their colleagues is a strong stimulus to re-examine their care patterns and make changes. This validates the ideal that doctors are motivated by doing the right thing for the patient, rather than financial incentives. Receiving new information about how they can more closely align with “doing the right thing” is sufficient to quickly change behavior.
In November 2013, a small group of family doctors gathered around a table in Rohnert Park, California and discussed what to do when patients requested a lab test to check for Vitamin D levels. Sources on social media and TV were telling patients they should get tested, while simultaneously, the doctors were receiving messages from their own specialty societies telling them that the Vitamin D test was something that often added little and had no clinical value. The Choosing Wisely campaign suggests that too many tests are being ordered which leads to unnecessary costs and results in what is labeled “low value care.” But what to do when patients are adamant they want the test and a difficult conversation denying such a request could lead to negative Yelp reviews? Each doctor is alone in this quandary and does their best to balance the competing interests.
Naturally, they each assume that the way they resolve this dilemma is reasonable and roughly the same as their colleagues. But they don’t really know for sure, because they do not normally receive any feedback about how they compare to each other.
All that changed when we showed the group of doctors in Rohnert Park how often each of them ordered Vitamin D tests compared to the others. The frequencies were shown in a graph with their names displayed clearly, so that each could see how their ordering differed from their peers. This unblinded peer comparison caused some awkward moments when it became clear that there was a fourfold range from the highest doctor at 16% to the lowest doctor at 4% per year.
To their credit, the awkward moment did not result in defensiveness, but rather curiosity and humor. After some laughter and teasing, the group embarked on a serious conversation about what the ideal frequency might be. But does just talking about it cause any real behavior change? Whether any of them would practice differently the next time a patient showed was an open question.
With the electronic health record systems now in place, it is easy to study what happened. By looking at each doctor’s test ordering pattern month after month, we found that almost all of them reduced how many Vitamin D tests they were ordering and the monthly group average went from 8% to 2% very quickly.
Bolstered by this success, our team replicated the same process with 56 other groups of clinicians. In the most recent group, with a large count of primary care clinicians, they saved $880,000 in Vitamin D testing.
With many patients now having high deductible plans, this created a significant reduction in out of pocket costs that was not adding any value to their health.
This process of gathering groups of clinicians together and letting them discover new insights about how they differ and how to turn that into real savings has been standardized and turned into a sustainable program that has spread throughout several organizations.
In reflecting on the lessons learned from this project and many similar ones to reduce potential unnecessary use of high cost drugs and lab or imaging tests, we found that the following are key success factors in this process:
Key success factors for implementing “Variation Reduction.”
Group setting for face to face conversation
Unblinded peer comparison
Trained facilitator to guide the conversation
Respectful, helpful approach, rather than ‘top down’
Clinicians’ conversation directs the ideal practice, rather than externally imposed standard.
Future blogs will be exploring these components in more detail.