Clinical trial NCT02247050: Primary Care Clinician Commitments to Choosing Wisely®
Official title: Primary Care Clinician Commitments to Choosing Wisely®
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Health Services Misuse
Physician's Practice Patterns
Guideline Adherence
Unnecessary Procedures
Health Care Costs
Keywords: Costs and Cost Analysis
Professional Practice
Attitude of Health Personnel
Health Knowledge, Attitudes, and Practice
Decision Making
Practice Guidelines as Topic
Physician-Patient Relations
Physician's Role
Health Care
Quality of Health Care
Quality Assurance
Physicians, Primary Care
Evidence-Based Medicine
Evidence-Based Practice
Decision Support Systems, Clinical
Reminder Systems
Judgment
Cognition
Patient Care
Health Services Misuse
Unnecessary Procedures
Prescribing Patterns, Physician
Inappropriate Prescribing
Over Prescribing
Low Back Pain
Sinusitis
Infections, Upper Respiratory
Generalized Headache
Imaging, Diagnostic
Antibiotics
Humans
Overuse of Low-Value Services
Pragmatic Trial
Stepped Wedge Design
Cluster Randomized Trial
Choosing Wisely
Lead sponsor: University of Michigan
Sponsor class: OTHER
Collaborators: name: Robert Wood Johnson Foundation
name: IHA
First posted: 2014-09-23
Enrollment: 45
Sex: ALL
Minimum age (years): 21
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: CROSSOVER
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: This pragmatic trial examines the uptake and effects of primary care clinician commitments to follow 3 Choosing Wisely® recommendations. The investigators hypothesize that pre-encounter invitations to clinicians to commit to the recommendations will decrease ordering of: (1) imaging tests for low back pain, (2) antibiotics for acute sinusitis, and (3) imaging tests for headaches. The study is a mixed-methods, stepped wedge cluster randomized trial in which the intervention will be sequentially introduced to 6 clinics in southeastern Michigan in a randomly assigned order.

Detailed description: Clinicians often make decisions about ordering low-value services in the midst of clinical encounters when their thinking can be rushed and susceptible to patient demands. This pragmatic trial examines the uptake and effects of shifting clinicians' decisions about ordering low-value services to the pre-encounter period when their thinking is slower and more deliberative; inviting clinicians to commit to avoid ordering those services during patient encounters; and providing to clinicians who committed decision support resources such as point-of-care reminders, patient education handouts, and access to brief communications training.

The investigators will conduct a mixed-methods, stepped wedge cluster randomized trial in 6 IHA primary care clinics in southeastern Michigan. The intervention will be introduced in each clinic in sequence approximately one month apart and in a randomly assigned order (i.e., temporal randomization). In each clinic the intervention will continue for 1 to 6 months so that the intervention ends in all clinics at the same time. For example, in the first clinic the intervention will run for 6 months; in the sixth clinic the intervention will run for 1 month. The total length of the control period plus the intervention period will be 8 months at all clinics.

Prior to the start of the study, IHA made its primary care clinicians aware of publicly available recommendations from the ABIM Foundation's Choosing Wisely® campaign applicable to avoiding overuse of low-value services for 3 common conditions: (1) low back pain, (2) acute sinusitis, and (3) headaches. However, research has shown that clinician behavior seldom changes as a result of information alone. Therefore, at the start of the intervention period clinicians will be invited to make a pre-encounter commitment to follow the 3 Choosing Wisely recommendations. Clinicians who choose to commit will throughout the intervention period receive point-of-care commitment reminders, Choosing Wisely patient education handouts, and weekly emails with decision support resources. Clinicians will remain free to order services at any time without penalty.

The investigators will measure whether the clinician-focused intervention leads to declines in rates of ordering imaging tests for low back pain, antibiotics for acute sinusitis, and imaging tests for headaches. The study team will analyze ordering patterns and costs using clinical operations datasets (drawn from electronic health records and from the billing and practice management system). The following hypotheses will be tested:

Hypothesis 1: Inviting primary care clinicians to commit to avoid ordering imaging for low back pain, antibiotics for acute sinusitis, and imaging for headaches will decrease ordering of these services.

Hypothesis 2: Inviting primary care clinicians to commit to avoid ordering imaging for low back pain, antibiotics for acute sinusitis, and imaging for headaches will reduce health care costs in patient visits for low back pain, acute sinusitis, and headaches.

Hypothesis 3: Inviting primary care clinicians to commit to avoid ordering low-value services will reduce per-clinician per-visit health care costs across clinical conditions.

For each outcome investigators will also compare differences between clinicians who did and did not commit to follow the 3 Choosing Wisely recommendations. Additionally, investigators will compare differences in outcomes between the 3-month follow-up period (immediately after the intervention has ended) and the control and intervention periods.

After the intervention period, the study team will conduct surveys and semi-structured interviews with study clinicians. The survey results will be used to identify correlates of primary care clinician uptake of invitations to commit to avoid ordering low-value services. The semi-structured interviews will elicit qualitative data on clinician attitudes towards overuse of low-value services, clinicians' responses to the intervention, and facilitators of and barriers to avoidance of delivering low-value care.

Eligibility criteria: Inclusion Criteria:

* Primary care clinicians in 6 primary care (family medicine and internal medicine) clinics within the IHA organization of Ann Arbor, Michigan

Exclusion Criteria:

* None

Primary outcomes:
measure: Composite rates of ordering 3 potentially low-value services in primary care visits by adult patients
timeFrame: Within 10 months of receiving the intervention
Secondary outcomes:
measure: Composite rates of ordering potential substitute services for 3 potentially low-value services in primary care visits by adult patients
timeFrame: Within 10 months of receiving the intervention
Other outcomes:
Locations:
city: Ann Arbor
country: United States
facility: IHA Ann Arbor Family Medicine
state: Michigan
city: Ann Arbor
country: United States
facility: IHA Family Medicine - Arbor Park
state: Michigan
city: Ann Arbor
country: United States
facility: IHA Internal Medicine - Domino's Farms
state: Michigan
city: Brighton
country: United States
facility: IHA Brighton Family Care
state: Michigan
city: Canton
country: United States
facility: IHA Internal Medicine - Cherry Hill
state: Michigan
city: Ypsilanti
country: United States
facility: IHA Reichert Internal Medicine at Towsley
state: Michigan
Study officials:
affiliation: University of Michigan
name: Jeffrey T. Kullgren, MD, MS, MPH
role: PRINCIPAL_INVESTIGATOR
References:
citation: Kullgren JT, Krupka E, Schachter A, Linden A, Miller J, Acharya Y, Alford J, Duffy R, Adler-Milstein J. Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial. BMJ Qual Saf. 2018 May;27(5):355-364. doi: 10.1136/bmjqs-2017-006699. Epub 2017 Oct 24.