Effects of Provider Commitments to Choose Wisely

University of Michigan

Status: Completed

Conditions: Health Services Misuse; Physician's Practice Patterns; Unnecessary Procedures; Health Care Costs; Guideline Adherence

Treatments: Other: Health Education Materials to Patients (Patient Intervention); Behavioral: Commitment Invitation for Clinicians (Clinician Intervention)

Study type: Interventional

Funder types: Other

Identifiers

NCT03411525

HUM00112834

Details and patient eligibility

About

Clinicians' decisions to order potentially unnecessary services -- such as those targeted in the Choosing Wisely® campaign -- are often affected by their high-pressure practice environments, which can make it hard to consistently avoid ordering low-value care. The field of behavioral economics offers a promising and highly scalable approach to decreasing use of low-value services: asking clinicians to commit to avoid ordering such services and providing them and their patients with resources to support adherence to this commitment. This project will evaluate the effects of such an intervention across 2 large health systems, Michigan Medicine and IHA, through a mixed-methods, stepped wedge cluster randomized trial. In each of the study clinics, clinicians will be invited to commit to following a set of targeted Choosing Wisely® recommendations. Clinicians who make such a commitment, and their patients, will receive access to key resources to support adherence to this commitment. To measure the effects of the intervention, automated clinical data and medical record data before and after the intervention will be examined. Surveys and semi-structured interviews of both clinicians and patients will also be conducted to determine the effects of the intervention on their decision-making and experiences.

Full description

A mixed-methods stepped wedge cluster randomized trial will be conducted in 8 primary care clinics of IHA, a private multispecialty group practice, and Michigan Medicine, a large academic health system. The study will test whether pre-encounter clinician commitments combined with patient and provider supports decrease overtreatment of type 2 diabetes among patients 65 and older, use of benzodiazepines and sedative-hypnotics among patients age 65 and older who have insomnia or anxiety, and use of PSA tests to screen for prostate cancer among men 75 and older. These 3 recommendations were chosen because they are commonly performed in primary care practice, have Choosing Wisely® recommendations against these low-value services, and represent situations in which clinician decisions about ordering of services can be unduly swayed by interactions with patients.

Enrollment: 489 patients

Sex: All

Ages: 18+ years old

Volunteers: Accepts Healthy Volunteers

Inclusion criteria

• Clinician participants will be drawn from the pool of physicians, nurse practitioners, and physician assistants staffing the 8 primary care clinics.

• Patients of all 8 study clinics must meet criteria for one of the three Choosing Wisely® recommendations to be eligible to participate:

  • 65 and older with type 2 diabetes
  • 65 and older with insomnia and/or anxiety
  • male, 75 and older with no history of prostate cancer.

Exclusion criteria

• Patients who have cognitive impairment and/or a serious psychiatric diagnosis will not be eligible to participate in the surveys or interviews.

Trial design

Primary purpose: Health Services Research

Allocation: Randomized

Interventional model: Crossover Assignment

Masking: None (Open label)

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489 participants in 8 patient groups

Commitment invitation at time 1

Experimental group

Description:

In the stepped wedge cluster randomized design, the first clinic will remain in the control period (no intervention) for 1 month, followed by a 1 month transition period (where data will not be collected), before crossing over to the intervention period for 8 months.

Treatment:

Behavioral: Commitment Invitation for Clinicians (Clinician Intervention)

Other: Health Education Materials to Patients (Patient Intervention)

Commitment invitation at time 2

Experimental group

Description:

In the stepped wedge cluster randomized design, the second clinic will remain in the control period (no intervention) for 2 months, followed by a 1 month transition period (where data will not be collected), before crossing over to the intervention period for 7 months.

Treatment:

Behavioral: Commitment Invitation for Clinicians (Clinician Intervention)

Other: Health Education Materials to Patients (Patient Intervention)

Commitment invitation at time 3

Experimental group

Description:

In the stepped wedge cluster randomized design, the third clinic will remain in the control period (no intervention) for 3 months, followed by a 1 month transition period (where data will not be collected), before crossing over to the intervention period for 6 months.

Treatment:

Behavioral: Commitment Invitation for Clinicians (Clinician Intervention)

Other: Health Education Materials to Patients (Patient Intervention)

Commitment invitation at time 4

Experimental group

Description:

In the stepped wedge cluster randomized design, the fourth clinic will remain in the control period (no intervention) for 4 months, followed by a 1 month transition period (where data will not be collected), before crossing over to the intervention period for 5 months.

Treatment:

Behavioral: Commitment Invitation for Clinicians (Clinician Intervention)

Other: Health Education Materials to Patients (Patient Intervention)

Commitment invitation at time 5

Experimental group

Description:

In the stepped wedge cluster randomized design, the fifth clinic will remain in the control period (no intervention) for 5 months, followed by a 1 month transition period (where data will not be collected), before crossing over to the intervention period for 4 months.

Treatment:

Behavioral: Commitment Invitation for Clinicians (Clinician Intervention)

Other: Health Education Materials to Patients (Patient Intervention)

Commitment invitation at time 6

Experimental group

Description:

In the stepped wedge cluster randomized design, the sixth clinic will remain in the control period (no intervention) for 6 months, followed by a 1 month transition period (where data will not be collected), before crossing over to the intervention period for 3 months.

Treatment:

Behavioral: Commitment Invitation for Clinicians (Clinician Intervention)

Other: Health Education Materials to Patients (Patient Intervention)

Commitment invitation at time 7

Experimental group

Description:

In the stepped wedge cluster randomized design, the seventh clinic will remain in the control period (no intervention) for 7 months, followed by a 1 month transition period (where data will not be collected), before crossing over to the intervention period for 2 months.

Treatment:

Behavioral: Commitment Invitation for Clinicians (Clinician Intervention)

Other: Health Education Materials to Patients (Patient Intervention)

Commitment invitation at time 8

Experimental group

Description:

In the stepped wedge cluster randomized design, the eighth clinic will remain in the control period (no intervention) for 8 months, followed by a 1 month transition period (where data will not be collected), before crossing over to the intervention period for 1 month.

Treatment:

Behavioral: Commitment Invitation for Clinicians (Clinician Intervention)

Other: Health Education Materials to Patients (Patient Intervention)