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Kullgren JT, Krupka E, Schachter A, Linden A, Miller J, Alford J, Duffy R, Adler-Milstein J. Commitment to Choosing Wisely® is a low cost, scalable strategy that can decrease clinician ordering of services that can lead to over diagnosis. Paper presented at: Preventing Overdiagnosis Annual Conference; 2016 Sep 20; Barcelona, Spain.
Objectives: Clinicians order services that can lead to overdiagnosis because of a range of cultural, structural, and behavioral factors. Little is known about how these factors could be modified to decrease ordering of such services. We tested whether a low-cost intervention grounded in behavioral economics could decrease ordering of services that can lead to overdiagnosis and examined how clinicians felt this strategy changed patient encounters and clinical decision making. Method: We conducted a mixed methods, stepped wedge cluster randomized trial with 45 primary care clinicians in 6 clinics in the United States. 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 6-month intervention period, clinicians were invited to commit to following these recommendations. Clinicians who committed received point-of-care reminders of their commitment and patient education handouts, along with weekly emails with resources to improve communication with patients about unnecessary services. The primary outcome was the difference between the intervention and control periods in the proportion of applicable visits with orders for the targeted services. A secondary outcome was the difference between the intervention and control periods in the proportion of visits with potential substitute orders for each condition. We estimated differences in proportions using linear mixed models with random effects for providers nested in practices, adjusted for patient characteristics, time, and diagnosis. After the intervention, we interviewed study clinicians about their experiences. Results: All 45 clinicians committed to following the 3 Choosing Wisely recommendations. Across 18,013 clinic visits, 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). In interviews with 24 study clinicians, 14 felt the intervention improved their conversations with patients about the targeted services and 10 felt the intervention changed their practice patterns. Conclusions: A behavioral economic intervention that changed clinicians' choice environments by pairing commitment to following 3 Choosing Wisely recommendations with supports to promote adherence to this commitment produced fewer orders for services that can lead to overdiagnosis. To promote sustained improvements in care, this strategy could be embedded in routine practice but should account for potential substitute services. Submitting author: Jeffrey T. Kullgren VA Ann Arbor Healthcare System and University of Michigan (734) 845-3613 email@example.com