Reducing care variation is central to health systems’ broader efforts to improve patient outcomes and operational efficiency. But aligning physicians around evidence-based practice — especially when it means doing something differently than how they were trained — can be a challenge.
David Christensen, MD, senior vice president of medical affairs and chief physician executive at Madera, Calif.-based Valley Children’s Healthcare, points to the treatment of bronchiolitis as a case in point. The common viral infection affects young children and targets small airways in the lungs. For decades, standard treatment involved steroids, antibiotics and bronchodilators — medications that relax muscles in the lungs to widen the airways and make it easier to breathe. Chest X-rays were also widely used to diagnose the condition.
But in 2006, the American Academy of Pediatrics published evidence-based practice guidelines that recommended a shift away from the use of extensive diagnostic tests and medications. Instead, the condition should be diagnosed based on a patient’s history and physical exam, and should be treated primarily through supportive care.
The change was informed by a growing body of evidence over the years indicating more extensive treatment and management offers no significant benefit to most patients.
“It’s a complete change from the way we were trained many years ago,” Dr. Christensen said. “Not only is it better for the patient, but it’s also cost effective. You’re not exposing the child to extra radiation, you’re not giving them unnecessary antibiotics, and in addition, you’re saving the healthcare dollar and the state of society the cost of unnecessary testing and medications.”
But getting clinicians on board with the new recommendations took time, he said, especially among experienced physicians. When the system first started embedding evidence-based protocols and order sets in the EHR for the condition, there was pushback from physicians who felt the protocols infringed on their clinical judgment and autonomy.
Over time, however, consistent communication helped shift perceptions. Leaders shared updated guidance from reputable sources and clearly explained the “why” behind the protocols: providing more effective, lower-cost care to patients. Today, the protocols are widely accepted as standard practice.
“As we’ve shared the evidence and strength of that evidence, the physicians have really come around to it and have embraced this as an order set that, if you’re going to change it, you have to physically make an effort to order that X-ray,” Dr. Christensen said. “It does allow for variation to some extent. But for the most part, it’s our expectation that doctors utilize that and follow what is considered evidence-based care.”
