Change Theory Contributes to Choosing Wisely for Immune Thrombocytopenia.

OBJECTIVES: Despite 2011 guidelines in which it is suggested that treatment of acute immune thrombocytopenia purpura (aITP) is not needed for patients without significant bleeding, only 14% of children treated for aITP have bleeding symptoms. Our aim was to decrease the percentage of children with first-episode aITP who were unnecessarily treated by 50% within 12 months of guideline implementation.

METHODS: An intervention was designed by using the precaution-adoption-process model. A standard-of-practice meeting was organized and focused on clinician readiness for change. After education on current evidence and common cognitive errors, consensus clinical guidelines were created. After implementation, an article in a statewide professional newsletter was published to educate community providers. Unnecessary treatment (UT) was defined as treatment of any patient who only had bruising and/or self-resolving nose bleeds. Statistical process control charts were used to track progress, midline shifts were determined by Nelson's rules, and hospital costs were derived from administrative billing data.

RESULTS: One hundred children with aITP were seen from January 2013 to September 2018. UT decreased from 70% to a sustained rate of <30% ( P = .008), including a mean of 7% over the past 12 months. The admission rate decreased from 100% to 52% ( P = .013), and the total percentage of patients treated decreased from 100% to 48% ( P = .016), with both numbers continuing to decline. No adverse bleeding events occurred. An estimated 12 admissions, 4 readmissions, and 5 adverse events were avoided annually.

CONCLUSIONS: We demonstrated successful improvement in UT of aITP through an educational intervention informed by the precaution-adoption-process model change theory.