Promoting Choosing Wisely Thyroid Function Test Guidelines in a Large Pediatric Hospital System.

BACKGROUND: Free thyroxine (fT4) is often ordered when not indicated. The goal of the current study was to use quality improvement tools to identify and implement an optimal approach to reduce inappropriate fT4 testing throughout a large pediatric hospital system. METHODS: After reviewing evidence-based guidelines and best practices, a thyroid-stimulating hormone with reflex to fT4 test and an outpatient thyroid order panel with clinical decision support at order entry, along with several rounds of provider education and feedback, were implemented. Outpatient and inpatient order sets and system preference lists were reviewed with subject matter experts and revised when appropriate. Tracking metrics were identified. Automated monthly run charts and statistical process control charts were created using data retrieved from the electronic health record. Charts established baseline data, balancing measure data, monitored the impact of interventions, and identified future interventions. RESULTS: Over a 44-month period, among nonendocrinology providers, a reduction in fT4 and thyroid-stimulating hormone co-orders from 67% to 15% and an increase in reflex fT4 tests from 0% to 77% was obtained in inpatient and outpatient settings. Direct cost savings as a result of performing 5179 fewer fT4 tests over 3 years was determined to be $45 800. CONCLUSIONS: After implementation of a reflex fT4 test, a novel order panel with clinical decision support, provider education, and changes to ordering modes, a large and sustainable reduction in fT4 tests that was associated with significant cost savings was achieved among nonendocrinology providers.

Improving Lead Screening Rates in a Large Pediatric Primary Care Network.

Exposure to environmental lead continues to be a significant public health concern. Elevated blood lead levels can lead to neurocognitive delays and other adverse health outcomes. Unfortunately, screening rates in most communities remain low. This quality improvement project aimed to improve universal screening at 12 months of age and increase screening rates from 71% to 95%. The project team also aimed to improve risk-based screening at 24 months of age to increase screening rates from 41% to 70%. METHODS: This project utilized the Model for Improvement. After identifying key drivers, the team designed, tested, and adopted a series of interventions to improve lead screening. Dynamic order sets were developed that pre-checked the lead order, if appropriate, based on the patient's age, previous results, and risk factors. Sites received regular feedback on their screening rates. RESULTS: The percentage of patients receiving universal lead screening at their 12-month well visit increased from 71% to 96%. 70% of 2-year-olds were at risk for lead exposure based on ZIP code and insurance provider. Development of dynamic orders for patients at risk increased screening rates from 41% to 74% at the 24-month well visit. CONCLUSIONS: Utilization of clinical decision support tools within an electronic health record can significantly increase the percentage of children screened for lead toxicity. Similar tools could identify patients due for other screens or interventions, resulting in improved care and patient outcomes.