Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial

Area of Science:

• Health Services Research
• Clinical Decision Making
• Evidence-Based Practice

Background:

• Discouraging clinicians from ordering low-value services is a significant challenge in healthcare.
• The Choosing Wisely campaign aims to reduce unnecessary medical tests and procedures.

Purpose of the Study:

• To evaluate if clinician precommitment to Choosing Wisely recommendations, supported by decision aids, can decrease potentially low-value orders.
• To assess the impact on specific conditions: uncomplicated low back pain, uncomplicated headaches, and acute sinusitis.

Main Methods:

• A 12-month stepped wedge cluster randomized trial involving 45 primary care providers across six clinics.
• Clinicians precommitted to specific Choosing Wisely recommendations and received point-of-care reminders, patient education, and communication resources.
• Primary outcome: change in percentage of visits with potentially low-value orders; secondary outcomes: alternate orders and sustained effects.

Main Results:

• The intervention did not significantly change low-value orders for headaches or acute sinusitis.
• A 1.7% increase in alternate orders was observed overall (p=0.01).
• For low back pain, a 1.2% decrease in low-value imaging orders (p=0.001) and a 1.9% increase in alternate orders (p=0.007) were noted. No sustained effects were observed post-intervention.

Conclusions:

• Clinician precommitment to Choosing Wisely recommendations had a limited and unsustained impact on reducing potentially low-value orders, effective only for low back pain imaging.
• The intervention may have inadvertently increased alternate orders, suggesting a need for refined strategies to reduce low-value care.