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Study: Patients Do Better When Physicians Follow Computerized Alerts

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When physicians follow computer alerts embedded in electronic health
records, their hospitalized patients experience fewer complications and
lower costs, leave the hospital sooner and are less likely to be
readmitted, according to a study of inpatient care.

The research examined alerts that popped up on physician computer
screens when their care instructions deviated from evidence-based
guidelines.

The alerts were based on an initiative called Choosing Wisely, which
identifies common tests and procedures that may not have clear benefit
for patients and should sometimes be avoided. For example, an alert
might pop up on the screen if a physician orders a CT scan when it's
unnecessary and likely won't improve the patient's outcome. The alert
would serve as a reminder that the order could expose the patient to
unnecessary radiation and costs.

The Choosing Wisely alerts were backed by the American Board of Internal
Medicine Foundation and created by various physician subspecialty
societies.

"Sometimes the best care for certain patient conditions means doing
less," said Scott
Weingarten, MD, MPH
, chief clinical transformation officer at Cedars-Sinai
and a senior author of the study. "We have seen that real-time aids for
clinical decision-making can potentially help physicians reduce
low-value care and improve patient outcomes while lowering costs."

Many leaders in the healthcare industry have targeted unnecessary care
as a means of improving patient safety while cutting wasteful spending.
One 2010 estimate from the Institute of Medicine found that "unnecessary
services" contribute to about $210 billion in wasteful healthcare
spending in the United States each year.

The study, conducted by investigators from Cedars-Sinai and Optum
Advisory Services, was published in The
American Journal of Managed Care
. It examined data
from inpatient visits at Cedars-Sinai Medical Center from October 2013
to July 2016 in which one or more of the 18 most frequent alerts was
triggered.

For 26,424 of the inpatient visits studied, the treating physician
followed either all or none of the Choosing Wisely guidance. In 6
percent of visits, physicians in the "treatment group" followed all
triggered alerts; in the remaining 94 percent of visits, physicians in
the "control group" followed none of the triggered alerts. An alert was
triggered, for example, if a physician tried ordering a sedative for a
sleepless older patient or an appetite stimulant for an older patient
who was ill and losing weight. Sedatives can put seniors at risk for
falls, bone fractures and car accidents, and appetite stimulants can put
seniors at risk of fluid retention, stroke and death.

The authors found a significant difference in health outcomes and costs
between the two groups. For patients whose physicians did not follow the
alerts, the odds of complications increased by 29 percent compared to
the group whose physicians followed the alerts. Likewise, the odds of
hospital readmissions within 30 days of the patients' original visits
was 14 percent higher in the group whose physicians did not follow the
alerts. Patients of these physicians also saw a 6.2 percent increase in
their length of stay and an additional 7.3 percent – or $944 per patient
– in costs, after adjusting for differences in patient illness severity
and case complexity.

"Sometimes doctors order tests that they think are in the patient's best
interest, when research doesn't show that to be the case. Unnecessary
testing can lead to interventions that can cause harm," said Harry
C. Sax, MD
, executive vice chair of Surgery at Cedars-Sinai and a
senior author of the study. "This work is about giving the right care
that patients truly need."

The authors acknowledge limitations to the study. Their strict
definition of alert compliance, which excluded visits in which
physicians followed some but not all alerts, limited their understanding
of the clinical and financial impact of those visits. Additionally, the
investigators were unable to measure the impact of specific alerts on
outcomes to see if one alert was more significant than others. Finally,
it is possible that physicians with better patient outcomes and lower
costs are more likely to follow Choosing Wisely clinical decision
support alerts, rather than proving a "cause and effect" relationship
between following the alerts and better outcomes.

Disclosures: Optum is a licensed reseller of Stanson Health, including
its Choosing Wisely alert content evaluated in this study. Cedars-Sinai
is the major shareholder of Stanson Health and employs the company's
founders, Darren Dworkin, Cedars-Sinai chief information officer and
stockholder of Stanson Health, and Weingarten, who is chairman of the
board and stockholder of Stanson Health.

About Cedars-Sinai

Cedars-Sinai is a leader in providing high-quality healthcare
encompassing primary care, specialized medicine and research. Since
1902, Cedars-Sinai has evolved to meet the needs of one of the most
diverse regions in the nation, setting standards in quality and
innovative patient care, research, teaching and community service.
Today, Cedars-Sinai is known for its national leadership in transforming
healthcare for the benefit of patients. Cedars-Sinai impacts the future
of healthcare by developing new approaches to treatment and educating
tomorrow's health professionals. Additionally, Cedars-Sinai demonstrates
a commitment to the community through programs that improve the health
of its most vulnerable residents.

About Optum

Optum is a leading information and technology-enabled health services
business dedicated to helping make the health system work better for
everyone. With more than 135,000 people worldwide, Optum delivers
intelligent, integrated solutions that help to modernize the health
system and improve overall population health. Optum is part of
UnitedHealth Group (NYSE:UNH). For more information, visit www.optum.com.

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