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MOC Credit Provides “Sweet Cookie” Incentive for Improving Implementation

Wednesday, February 15, 2017 - 10:45

“Our goal was to reduce unnecessary tests.”

- Vineeta Mittal, MD, MBA

Clinical practice guidelines can be a very effective mechanism for sharing best practices in the treatment of many childhood diseases. In 2006, for example, the American Academy of Pediatrics published clinical practice guidelines on the treatment of bronchiolitis, a common cause of hospitalization in children from birth to age 2.

However, pediatricians at the Department of Pediatrics at University of Texas Southwestern (UTSW) Medical Center and Children’s Health System of Texas at Dallas noted that integrating all the guidelines into practice was challenging. Also, research suggests that guidelines are most effective when facilitated by local leaders.

​Vineeta Mittal, MD, MBA, Associate Professor of Pediatrics at the Department of Pediatrics at UTSW Medical Center and Children’s Health System of Texas, worked with colleagues to discover the variation in treatment for different children who were hospitalized in their medical center with bronchiolitis. They identified gaps between practice and evidence. As a result of their studies, they developed recommendations for institutional bronchiolitis clinical practice guidelines, which were published in Pediatrics. (Mittal V, Pediatrics 2014;133:e730–e737.)

Their work to improve practice has earned Maintenance of Certification (MOC) Part 4 credit for Dr. Mittal and other pediatricians working on the project. Now that UTSW has become an MOC portfolio sponsor, these pediatricians can continue to earn MOC Part 4 credit through their institution without the need for a separate application to the ABP.

“Many more pediatricians are taking time to participate in the guideline implementation since MOC credit is awarded,” Dr. Mittal said. “It’s an important and easily achievable incentive.”

In the initial study, a team of physicians—emergency department, hospitalists, general pediatricians and subspecialists in infectious disease, pulmonology and critical care medicine—as well as nurses and respiratory therapists, reviewed standards of care at Children’s Health System and at other institutions. They also reviewed the literature on treatment of bronchiolitis.

“Our goal was to reduce unnecessary tests and treatments and develop a value-based model. So we focused our interventions to reduce the number of chest X-rays we were performing and reduce the use of bronchodilators, steroids and antibiotics,” Dr. Mittal said. “We also wanted to try to reduce the length of hospital stay.”

In addition to developing clinical practice guidelines, the team used different methods to remind doctors to follow the guidelines. For example, they used lectures, emails, computer screen savers and laminated pocket-sized copies of key guideline recommendations.

Results from the study showed a reduction of chest X-rays from 60 percent of children in the control group (the season before the local guidelines were in place) to 45 percent the first season of the new guidelines and 39 percent the second season of the guidelines.

A control chart (below) shows a sustained reduction in chest X-ray use between pre- and post-implementation periods in the eligible patients. The horizontal black dashed line represents the average chest X-ray use during each season. Monthly run charts show a consistently sustained downward trend.

The team also found that bronchodilator use decreased from 27 percent in the control group to 20 percent in the first season and to 14 percent in the second season. Antibiotic use was reduced as well, from 37 percent in the control group to 35 percent in the first season and to 25 percent in the second season. Moreover, the average length of stay in the hospital dropped from 2.3 days for the control group to 1.8 days in the first and second seasons, with no significant change in readmission rates.

Now, based on these apparent improvements, the Department of Pediatrics at UTSW is collaborating with eight hospitals across Texas through the CHAT (Children’s Hospitals Across Texas) network to implement and update the guidelines and metrics for measuring their effectiveness. The hospital has also developed and tested guidelines for musculoskeletal disorders and management of asthma in hospitalized children.

“People are motivated to make these changes because it’s the right thing to do,” Dr. Mittal said, “and getting MOC credit is a very sweet cookie to encourage them to participate.”