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Original research
Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial
  1. Jeffrey Todd Kullgren1,2,3,4,
  2. Erin Krupka5,
  3. Abigail Schachter6,
  4. Ariel Linden7,
  5. Jacquelyn Miller4,
  6. Yubraj Acharya6,
  7. James Alford8,
  8. Richard Duffy9,
  9. Julia Adler-Milstein3,5,6
  1. 1 Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
  2. 2 Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
  3. 3 Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
  4. 4 Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
  5. 5 School of Information, University of Michigan, Ann Arbor, MI, USA
  6. 6 School of Public Health, University of Michigan, Ann Arbor, MI, USA
  7. 7 Linden Consulting Group, Ann Arbor, Michigan, USA
  8. 8 Division of Family Medicine, IHA, Ann Arbor, Michigan, USA
  9. 9 Division of Quality and Performance Improvement, IHA, Ann Arbor, MI, USA
  1. Correspondence to Dr Jeffrey Todd Kullgren, VA Ann Arbor Healthcare System and University of Michigan, PO Box 130170, Ann Arbor, Michigan 48113, USA; jkullgre{at}med.umich.edu

Abstract

Background Little is known about how to discourage clinicians from ordering low-value services. Our objective was to test whether clinicians committing their future selves (ie, precommitting) to follow Choosing Wisely recommendations with decision supports could decrease potentially low-value orders.

Methods We conducted a 12-month stepped wedge cluster randomised trial among 45 primary care physicians and advanced practice providers in six adult primary care clinics of a US community group practice.Clinicians were invited to precommit to Choosing Wisely recommendations against imaging for uncomplicated low back pain, imaging for uncomplicated headaches and unnecessary antibiotics for acute sinusitis. Clinicians who precommitted received 1–6 months of point-of-care precommitment reminders as well as patient education handouts and weekly emails with resources to support communication about low-value services.The primary outcome was the difference between control and intervention period percentages of visits with potentially low-value orders. Secondary outcomes were differences between control and intervention period percentages of visits with possible alternate orders, and differences between control and 3-month postintervention follow-up period percentages of visits with potentially low-value orders.

Results The intervention was not associated with a change in the percentage of visits with potentially low-value orders overall, for headaches or for acute sinusitis, but was associated with a 1.7% overall increase in alternate orders (p=0.01). For low back pain, the intervention was associated with a 1.2% decrease in the percentage of visits with potentially low-value orders (p=0.001) and a 1.9% increase in the percentage of visits with alternate orders (p=0.007). No changes were sustained in follow-up.

Conclusion Clinician precommitment to follow Choosing Wisely recommendations was associated with a small, unsustained decrease in potentially low-value orders for only one of three targeted conditions and may have increased alternate orders.

Trial registration number NCT02247050; Pre-results.

  • primary care
  • decision making
  • ambulatory care
  • decision support, clinical
  • health services research

https://doi.org/10.1136/bmjqs-2017-006699

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    Footnotes

    • Funding This work was funded by the Robert Wood Johnson Foundation (grant number 71475). Support was also provided by the US Department of Veterans Affairs (VA). Dr Kullgren was supported by a VA Health Services Research & Development Career Development Award (grant number 13-267). The funding sources had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; or preparation, review or approval of the manuscript.

    • Competing interests JTK has received research grants from the US Department of Veterans Affairs Health Services Research & Development (HSR&D) Service, Robert Wood Johnson Foundation, Donaghue Foundation, and Center for Medicare & Medicaid Services (CMS); received consulting fees from SeeChange Health and HealthMine; and received speaking honoraria from AbilTo. EK has received research grants from the Robert Wood Johnson Foundation, Donaghue Foundation and National Science Foundation. JM has received research grants from the Donaghue Foundation, Agency for Healthcare Research and Quality, Commonwealth Fund, CMS, John A Hartford Foundation, California Health Care Foundation, DHHS – Office of the National Coordinator for Health IT, and Blue Cross Blue Shield of Michigan Foundation. JM is on the advisory board of QPID Health.

    • Ethics approval The protocol was approved by the institutional review board of the University of Michigan Medical School (HUM00087820).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Patient-level data, statistical code and the trial protocol are available from the corresponding author at jkullgre@med.umich.edu. Consent for data sharing was not obtained from participants but the presented data are anonymised and risk of identification is low.

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