Market Overview

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

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
  • 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
, 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. 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,
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

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