A common reason for referrals to orthopedic specialists at Children's Hospital Boston is adolescent idiopathic scoliosis (AIS). However, in 2009, only 40 percent of referred visits met the screened criteria for an appropriate referral based on physical exam and scoliometer readings.
Driving over-referrals were unclear guidelines, provider knowledge deficits and parental preference. As a result, specialists' practices were oversubscribed and offices were overcrowded with essentially healthy children, and the cost of care increased.
The Pediatric Physicians' Organization at Children's (PPOC)—a group of more than 250 Massachusetts primary care physicians in 76 practices affiliated with Children's—collaborated with Children's pediatric orthopedists to develop tools for improving the efficiency of referrals for AIS. Over the course of 18 months, the Scoliosis Collaborative Initiative developed a decision support algorithm, didactics and feedback data for clinicians and educational handouts for parents. Relevant materials were integrated into the PPOC's electronic medical records (EMR) via the scoliosis order set.
Using the tools provided by the Scoliosis Collaborative Initiative, PPOC practices were able to decrease their AIS referrals by 24 percent. Project leaders learned that when it comes to changing referral patterns:
- Background analysis is critical
- Providers will make change faster if equipped with tools (e.g., decision support algorithm) and data (e.g., performance gap analysis)
- Educating families is essential