Deimplementation of routine chest X-rays in adult intensive care units

Silas P. Trumbo; Wade T. Iams; Heather M. Limper; Kathryn Goggins; Jayme Gibson; Lauren Oliver; David L. Leverenz; Lauren R. Samuels; Donald W. Brady; Sunil Kripalani

doi:10.12788/jhm.3129

Deimplementation of routine chest X-rays in adult intensive care units

Silas P. Trumbo, Wade T. Iams, Heather M. Limper, Kathryn Goggins, Jayme Gibson, Lauren Oliver, David L. Leverenz, Lauren R. Samuels, Donald W. Brady, Sunil Kripalani^*

^*Corresponding author for this work

Emergency Medicine

Research output: Contribution to journal › Article › peer-review

11 Scopus citations

Abstract

BACKGROUND: Choosing Wisely® is a national initiative to deimplement or reduce low-value care. However, there is limited evidence on the effectiveness of strategies to influence ordering patterns. OBJECTIVE: We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. DESIGN: We conducted a prospective, nonrandomized study with control data from a historical period. Qualitative evaluation was guided by the Consolidated Framework for Implementation Research. SETTING: The study was performed in the medical intensive care unit (MICU) and cardiovascular intensive care unit (CVICU) of an academic medical center in the United States from October 2015 to June 2016. PARTICIPANTS: The initiative included the staff of the MICU and CVICU (physicians, surgeons, nurse practitioners, fellows, residents, medical students, and X-ray technologists). INTERVENTION COMPONENTS: We utilized provider education, peer champions, and weekly data feedback of CXR ordering rates. MEASUREMENTS: We analyzed the CXR ordering rates and factors facilitating or inhibiting deimplementation. RESULTS: Segmented linear time-series analysis suggested a small but statistically significant decrease in CXR ordering rates in the CVICU (P < .001) but not in the MICU. Facilitators of deimplementation, which were more prominent in the CVICU, included engagement of peer champions, stable staffing, and regular data feedback. Barriers included the need to establish goal CXR ordering rates, insufficient intervention visibility, and waning investment among medical residents in the MICU due to frequent rotation and competing priorities. CONCLUSIONS: Intervention modestly reduced CXRs ordered in one of two ICUs evaluated. Understanding why adoption differed between the two units may inform future interventions to deimplement low-value diagnostic tests.

Original language	English (US)
Pages (from-to)	83-89
Number of pages	7
Journal	Journal of Hospital Medicine
Volume	14
Issue number	2
DOIs	https://doi.org/10.12788/jhm.3129
State	Published - Feb 2019

Funding

The authors thank the VUMC Choosing Wisely committee; Mr. Bill Harrell in Advanced Data Analytics for developing the Tableau platform used in our data feedback strategy; Emily Feld, MD, Jerry Zifodya, MD, and Ryan Kindle, MD for assisting with data feedback to providers in the MICU; Todd Rice, MD, Director of the MICU, for his support of the initiative; and Beth Prusaczyk, PhD, MSW and David Stevenson, PhD for providing feedback on earlier drafts of this manuscript. Disclosures: Dr. Kripalani reports personal fees from Verustat, personal fees from SAI Interactive, and equity from Bioscape Digital, outside the submitted work. All other authors have nothing to disclose. Funding: This work was supported by an Innovation Grant from the Alliance for Academic Internal Medicine (AAIM, 2016) and by the Departments of Internal Medicine and Graduate Medical Education at Vanderbilt University Medical Center. The AAIM did not have a role in the study design, data collection, data analysis, data interpretation, or manuscript writing. The authors thank the VUMC Choosing Wisely committee; Mr. Bill Harrell in Advanced Data Analytics for developing the Tableau platform used in our data feedback strategy; Emily Feld, MD, Jerry Zifodya, MD, and Ryan Kindle, MD for assisting with data feedback to providers in the MICU; Todd Rice, MD, Director of the MICU, for his support of the initiative; and Beth Prusaczyk, PhD, MSW and David Stevenson, PhD for providing feedback on earlier drafts of this manuscript. Funding: This work was supported by an Innovation Grant from the Alliance for Academic Internal Medicine (AAIM, 2016) and by the Departments of Internal Medicine and Graduate Medical Education at Vanderbilt University Medical Center. The AAIM did not have a role in the study design, data collection, data analysis, data interpretation, or manuscript writing.

ASJC Scopus subject areas

Fundamentals and skills
Care Planning
Assessment and Diagnosis
Health Policy
Leadership and Management
Internal Medicine

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10.12788/jhm.3129

Cite this

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title = "Deimplementation of routine chest X-rays in adult intensive care units",

abstract = "BACKGROUND: Choosing Wisely{\textregistered} is a national initiative to deimplement or reduce low-value care. However, there is limited evidence on the effectiveness of strategies to influence ordering patterns. OBJECTIVE: We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. DESIGN: We conducted a prospective, nonrandomized study with control data from a historical period. Qualitative evaluation was guided by the Consolidated Framework for Implementation Research. SETTING: The study was performed in the medical intensive care unit (MICU) and cardiovascular intensive care unit (CVICU) of an academic medical center in the United States from October 2015 to June 2016. PARTICIPANTS: The initiative included the staff of the MICU and CVICU (physicians, surgeons, nurse practitioners, fellows, residents, medical students, and X-ray technologists). INTERVENTION COMPONENTS: We utilized provider education, peer champions, and weekly data feedback of CXR ordering rates. MEASUREMENTS: We analyzed the CXR ordering rates and factors facilitating or inhibiting deimplementation. RESULTS: Segmented linear time-series analysis suggested a small but statistically significant decrease in CXR ordering rates in the CVICU (P < .001) but not in the MICU. Facilitators of deimplementation, which were more prominent in the CVICU, included engagement of peer champions, stable staffing, and regular data feedback. Barriers included the need to establish goal CXR ordering rates, insufficient intervention visibility, and waning investment among medical residents in the MICU due to frequent rotation and competing priorities. CONCLUSIONS: Intervention modestly reduced CXRs ordered in one of two ICUs evaluated. Understanding why adoption differed between the two units may inform future interventions to deimplement low-value diagnostic tests.",

author = "Trumbo, {Silas P.} and Iams, {Wade T.} and Limper, {Heather M.} and Kathryn Goggins and Jayme Gibson and Lauren Oliver and Leverenz, {David L.} and Samuels, {Lauren R.} and Brady, {Donald W.} and Sunil Kripalani",

note = "Funding Information: The authors thank the VUMC Choosing Wisely committee; Mr. Bill Harrell in Advanced Data Analytics for developing the Tableau platform used in our data feedback strategy; Emily Feld, MD, Jerry Zifodya, MD, and Ryan Kindle, MD for assisting with data feedback to providers in the MICU; Todd Rice, MD, Director of the MICU, for his support of the initiative; and Beth Prusaczyk, PhD, MSW and David Stevenson, PhD for providing feedback on earlier drafts of this manuscript. Disclosures: Dr. Kripalani reports personal fees from Verustat, personal fees from SAI Interactive, and equity from Bioscape Digital, outside the submitted work. All other authors have nothing to disclose. Funding: This work was supported by an Innovation Grant from the Alliance for Academic Internal Medicine (AAIM, 2016) and by the Departments of Internal Medicine and Graduate Medical Education at Vanderbilt University Medical Center. The AAIM did not have a role in the study design, data collection, data analysis, data interpretation, or manuscript writing. Funding Information: The authors thank the VUMC Choosing Wisely committee; Mr. Bill Harrell in Advanced Data Analytics for developing the Tableau platform used in our data feedback strategy; Emily Feld, MD, Jerry Zifodya, MD, and Ryan Kindle, MD for assisting with data feedback to providers in the MICU; Todd Rice, MD, Director of the MICU, for his support of the initiative; and Beth Prusaczyk, PhD, MSW and David Stevenson, PhD for providing feedback on earlier drafts of this manuscript. Funding: This work was supported by an Innovation Grant from the Alliance for Academic Internal Medicine (AAIM, 2016) and by the Departments of Internal Medicine and Graduate Medical Education at Vanderbilt University Medical Center. The AAIM did not have a role in the study design, data collection, data analysis, data interpretation, or manuscript writing. Publisher Copyright: {\textcopyright} 2019 Society of Hospital Medicine.",

year = "2019",

month = feb,

doi = "10.12788/jhm.3129",

language = "English (US)",

volume = "14",

pages = "83--89",

journal = "Journal of Hospital Medicine",

issn = "1553-5592",

publisher = "John Wiley and Sons Inc.",

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TY - JOUR

T1 - Deimplementation of routine chest X-rays in adult intensive care units

AU - Trumbo, Silas P.

AU - Iams, Wade T.

AU - Limper, Heather M.

AU - Goggins, Kathryn

AU - Gibson, Jayme

AU - Oliver, Lauren

AU - Leverenz, David L.

AU - Samuels, Lauren R.

AU - Brady, Donald W.

AU - Kripalani, Sunil

N1 - Funding Information: The authors thank the VUMC Choosing Wisely committee; Mr. Bill Harrell in Advanced Data Analytics for developing the Tableau platform used in our data feedback strategy; Emily Feld, MD, Jerry Zifodya, MD, and Ryan Kindle, MD for assisting with data feedback to providers in the MICU; Todd Rice, MD, Director of the MICU, for his support of the initiative; and Beth Prusaczyk, PhD, MSW and David Stevenson, PhD for providing feedback on earlier drafts of this manuscript. Disclosures: Dr. Kripalani reports personal fees from Verustat, personal fees from SAI Interactive, and equity from Bioscape Digital, outside the submitted work. All other authors have nothing to disclose. Funding: This work was supported by an Innovation Grant from the Alliance for Academic Internal Medicine (AAIM, 2016) and by the Departments of Internal Medicine and Graduate Medical Education at Vanderbilt University Medical Center. The AAIM did not have a role in the study design, data collection, data analysis, data interpretation, or manuscript writing. Funding Information: The authors thank the VUMC Choosing Wisely committee; Mr. Bill Harrell in Advanced Data Analytics for developing the Tableau platform used in our data feedback strategy; Emily Feld, MD, Jerry Zifodya, MD, and Ryan Kindle, MD for assisting with data feedback to providers in the MICU; Todd Rice, MD, Director of the MICU, for his support of the initiative; and Beth Prusaczyk, PhD, MSW and David Stevenson, PhD for providing feedback on earlier drafts of this manuscript. Funding: This work was supported by an Innovation Grant from the Alliance for Academic Internal Medicine (AAIM, 2016) and by the Departments of Internal Medicine and Graduate Medical Education at Vanderbilt University Medical Center. The AAIM did not have a role in the study design, data collection, data analysis, data interpretation, or manuscript writing. Publisher Copyright: © 2019 Society of Hospital Medicine.

PY - 2019/2

Y1 - 2019/2

N2 - BACKGROUND: Choosing Wisely® is a national initiative to deimplement or reduce low-value care. However, there is limited evidence on the effectiveness of strategies to influence ordering patterns. OBJECTIVE: We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. DESIGN: We conducted a prospective, nonrandomized study with control data from a historical period. Qualitative evaluation was guided by the Consolidated Framework for Implementation Research. SETTING: The study was performed in the medical intensive care unit (MICU) and cardiovascular intensive care unit (CVICU) of an academic medical center in the United States from October 2015 to June 2016. PARTICIPANTS: The initiative included the staff of the MICU and CVICU (physicians, surgeons, nurse practitioners, fellows, residents, medical students, and X-ray technologists). INTERVENTION COMPONENTS: We utilized provider education, peer champions, and weekly data feedback of CXR ordering rates. MEASUREMENTS: We analyzed the CXR ordering rates and factors facilitating or inhibiting deimplementation. RESULTS: Segmented linear time-series analysis suggested a small but statistically significant decrease in CXR ordering rates in the CVICU (P < .001) but not in the MICU. Facilitators of deimplementation, which were more prominent in the CVICU, included engagement of peer champions, stable staffing, and regular data feedback. Barriers included the need to establish goal CXR ordering rates, insufficient intervention visibility, and waning investment among medical residents in the MICU due to frequent rotation and competing priorities. CONCLUSIONS: Intervention modestly reduced CXRs ordered in one of two ICUs evaluated. Understanding why adoption differed between the two units may inform future interventions to deimplement low-value diagnostic tests.

AB - BACKGROUND: Choosing Wisely® is a national initiative to deimplement or reduce low-value care. However, there is limited evidence on the effectiveness of strategies to influence ordering patterns. OBJECTIVE: We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. DESIGN: We conducted a prospective, nonrandomized study with control data from a historical period. Qualitative evaluation was guided by the Consolidated Framework for Implementation Research. SETTING: The study was performed in the medical intensive care unit (MICU) and cardiovascular intensive care unit (CVICU) of an academic medical center in the United States from October 2015 to June 2016. PARTICIPANTS: The initiative included the staff of the MICU and CVICU (physicians, surgeons, nurse practitioners, fellows, residents, medical students, and X-ray technologists). INTERVENTION COMPONENTS: We utilized provider education, peer champions, and weekly data feedback of CXR ordering rates. MEASUREMENTS: We analyzed the CXR ordering rates and factors facilitating or inhibiting deimplementation. RESULTS: Segmented linear time-series analysis suggested a small but statistically significant decrease in CXR ordering rates in the CVICU (P < .001) but not in the MICU. Facilitators of deimplementation, which were more prominent in the CVICU, included engagement of peer champions, stable staffing, and regular data feedback. Barriers included the need to establish goal CXR ordering rates, insufficient intervention visibility, and waning investment among medical residents in the MICU due to frequent rotation and competing priorities. CONCLUSIONS: Intervention modestly reduced CXRs ordered in one of two ICUs evaluated. Understanding why adoption differed between the two units may inform future interventions to deimplement low-value diagnostic tests.

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Deimplementation of routine chest X-rays in adult intensive care units

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