Even professionals need coaching. It’s why the best major league pitchers still need a coach to visit the mound from time to time. Sometimes another experienced set of eyes can spot something even the pros missed, hopefully heading off problems before they become bad habits. For pitchers, results are measured in hits and runs, walks and strikeouts. In medicine, it works much the same way. Winning is always the goal, but like a pitcher perfecting a delivery, doctors constantly need to evaluate whether their process is in the best interest of patients and in line with current standards of care. Sometimes, that means more teaching.
That’s especially true when new standards of care need to be incorporated into what for many clinicians has become a routine. Recently, new data from the Corporal Michael J. Crescenz Veterans Affairs Medical Center in Philadelphia showed that doctors there were ordering bone scans at three times the national rate for a certain group of prostate cancer patients.
Bone scans are imaging tests that can detect cancer cells. Doctors inject a small amount of radioactive material into a vein and let it travel through the bloodstream. Along the way, the material collects in any cancer cells hidden in bones, making them visible to a scanner. It can be particularly useful in some cases of prostate cancer – which is known to spread to bones.
However, men with low-risk, non-aggressive types of prostate cancer don’t need bone scans because their cancer will rarely spread to bones. For these men, bone scans will simply cause inconvenience, use up resources, and cost money. Studies have found they can also give false positives, leading to additional testing and potentially causing emotional distress for patients. For all of these reasons, current medical standards consider bone scans a low-value test.
It’s so low-value that it even caught the attention of Congress. Guidelines in the new Medicare Access and CHIP Reauthorization Act, or MACRA, tie a medical practice’s reimbursements to certain quality metrics. The bill passed in 2015 and began tracking those measurements this year. One of those quality metrics for urologists and oncologists is the use of bone scans. Specifically, MACRA penalizes doctors who order them too frequently for low-risk patients.
Nationally, only 30 percent of low-risk prostate cancer patients receive bone scans. But at the VA in Philadelphia, data showed 32 out of 37 patients were sent for a scan from June 2013 to June 2014, an astronomical 86.5 percent. When researchers saw that the number was almost triple the national average, they called for a visit to the pitcher’s mound.
“We wanted to test if an intervention could change this behavior,” said Eric Ojerholm, MD, an instructor of Radiation Oncology at Penn. Ojerholm and his colleagues at the VA designed a teaching program specifically aimed at guiding doctors away from ordering bone scans for these patients. He and his team published their findings in the journal Advances in Radiation Oncology.
The intervention was based on two theories from behavioral science. The first is known as social comparison, in which doctors are explicitly shown how their ordering habits compare to their peers. The second is called normative appeal, which essentially lays out best practices and “norms” from professional guidelines. These techniques have successfully changed physician behavior in other areas of medicine, such as the overuse of antibiotics. Penn even has a specific unit dedicated to this idea called the “Nudge” unit, which recently saw success in boosting flu vaccination rates.
Ojerholm and his team delivered a presentation at a tumor board – a meeting where oncologists and urologists discuss complex cases. The presentation in June of 2014 laid out the VA’s bone scan rate versus other rates across the country. It also laid out current guidelines on the scans. They then led a discussion about how to incorporate this data into practice.
“We found a modest drop in the numbers, which shows our intervention may have made a difference,” Ojerholm said.
In the year that followed the session – specifically November 2014 through November 2015 – doctors at the VA ordered bone scans for 19 out of 29 patients, a rate of 65.5 percent. That’s down roughly 20 percentage points from pre-intervention levels.
“Our study shows doctors may be influenced by initiatives that combine peer comparison and a look at professional norms,” Ojerholm said.
While the initial results showed progress, Ojerholm says he’d like to see the approach studied further to find out if it will work in larger departments or with bigger groups of patients. He says it’s especially important given the new guidelines from the government.
“The MACRA regulations show it’s imperative to address this problem,” Ojerholm said of his effort to get doctors to throw the right pitch in the right situation. “Our intervention is just one potential way to do that.”