“Learn From Every Patient” to Improve Clinical Care

The Nationwide Children’s Hospital Cerebral Palsy team recently reported an evidence-based change in practice — eliminating annual screening X-rays in patients mildly affected by CP — facilitated by use of the Learn From Every Patient (LFEP) Program.

LFEP allows systematic data collection during all clinical encounters that meet the clinical documentation requirements while simultaneously informing quality improvement and research efforts.

“Hip displacement is a big problem for kids with cerebral palsy,” says Garey Noritz, MD, lead author on the study and Director of the Comprehensive Cerebral Palsy Program at Nationwide Children’s. “When we did the study, everybody that came to the clinic got an X-ray every year to look for hip displacement. It’s not a lot of radiation, but it’s a quantifiable amount of radiation every time you do it.”

Questioning the necessity of yearly screening led the team to examine the LFEP data collected for children with CP that is rated as mild, meaning no need for adaptive devices for mobility.

Between 2011 and 2014, 132 patients with mild CP were examined at the clinic; the mean age was 7.8 years (range, 1-22 years). These patients had a total of 212 pelvis X-rays, and thus, 424 hips were assessed. A majority (98.8 percent) were normal. Only five hips (1.2 percent) appeared to be displaced (<50 percent), but upon re-examination of the X-rays, all of these hips were minimally displaced (<30 percent). No patients needed hip-related treatment during the study period. Therefore, the team concluded that annual screening hip radiographs for patients with mild CP are not necessary.

The change reduces patient exposure to radiation (42-254 mRad per X-ray) and any potential radiation-related morbidity and simultaneously reduces costs (average of $66 per X-ray) for the family and/or insurance company.

“Two different things are going on,” says Dr Noritz, who is also a professor of Pediatrics at The Ohio State University. “First, we built this data system, which allows us to improve our research efforts and quality of care. Second, we built a multidisciplinary team with robust care coordination, which makes great efforts — the care coordinators, nurses, and social workers — to work with the families.”

For other institutions that are interested in starting programs similar to LFEP, Dr. Noritz advises that clinician buy-in is critical. “This essentially is a better way to do documentation and follow kids over time, and it gives you, as a clinician in the clinic or seeing certain trends, access to data to be able to look at those trends,” he says.

Citations:

1. Noritz G, Boggs A, Lowes LP, Smoyer WE. Learn From Every Patient. Pediatric Quality and Safety. 2018;3(5):e100.
2. Lowes LP, Noritz GH, Newmeyer A, Embi PJ, Yin H, Smoyer WE, ‘Learn from Every Patient’ Study Group. ‘Learn From Every Patient’: implementation and early results of a learning health system. Developmental Medicine & Child Neurology. 2017;59(2):183-191.