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A Randomized Trial of a Behavioral Economic Intervention to Decrease Overuse of Low-Value Health Services
Kullgren JT, Krupka E, Schachter A, Linden A, Miller J, Alford J, Adler-Milstein J. A Randomized Trial of a Behavioral Economic Intervention to Decrease Overuse of Low-Value Health Services. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2016 May 11; Hollywood, FL.
Background: Clinicians' decisions to order low-value health care services are typically made during clinical encounters, when their thinking can be rushed and susceptible to factors like patient demands. Inviting clinicians to commit to avoid ordering low-value services ahead of encounters when their thinking is often slower, and then providing point-of-care (POC) supports to promote adherence to this commitment, could potentially decrease such orders. The objective of this study was to test whether this behavioral economic strategy could decrease orders for low-value services for 3 common conditions.
Methods: We conducted a mixed-methods, stepped wedge cluster randomized trial in 3 internal medicine and 3 family medicine clinics of a private, multispecialty group practice. At the start of the control period, clinicians were shown Choosing Wisely recommendations to avoid imaging for uncomplicated low back pain, imaging for uncomplicated headaches, and unnecessary antibiotics for acute sinusitis. At the start of the intervention period, clinicians who consented to study participation were invited to commit to following these recommendations by signing a document. Clinicians who made this commitment received POC reminders of their commitment, POC patient education handouts, and weekly emails with resources to improve communications with patients about low-value care. After the 6-month intervention period there was a 3-month follow-up period. The primary outcome was the difference between the intervention and control periods in the proportion of visits with orders for the targeted low-value services. Secondary outcomes were the difference between the intervention and control periods in the proportion of visits with potential substitute orders for each condition, and the difference between the follow-up and control periods in the proportion of visits with orders for the targeted low-value services. We estimated differences in proportions using linear mixed models with random effects for providers nested in practices, adjusted for patient characteristics, time, and diagnosis. During the follow-up period, we interviewed study clinicians about their experiences with the intervention.
Results: Forty-five clinicians (85% of eligible clinicians) participated. All committed to following the 3 Choosing Wisely recommendations. The intervention was associated with a 1.4% decrease in the proportion of visits with orders for the targeted services (95% CI, -2.7% to -0.2%; P = 0.02), but also a 1.7% increase in the proportion of visits with potential substitute orders (95% CI, 0.2% to 3.2%; P = 0.02). There was no significant difference in the proportion of visits with orders for the targeted services in the follow-up period compared to the control period. In interviews with 24 study clinicians, 14 felt the intervention changed their conversations with patients about low-value care and 10 felt the intervention changed their practice styles.
Conclusions: We found that a behavioral economic intervention that paired an opportunity to commit to following Choosing Wisely recommendations with supports to promote adherence to this commitment was highly acceptable to primary care clinicians in a private practice environment, and associated with fewer orders for targeted low-value services. However, to promote sustained improvements in value this strategy may need to be fully integrated into routine care as well as account for potential substitute services.