番茄社区

Getting clinicians to commit to the Choosing Wisely recommendations somewhat reduced low-value care for older adults in common scenarios, a cluster randomized trial found.

After primary care clinicians committed in writing to the Choosing Wisely recommendations, the odds of their older patients undergoing a low-value service dropped by 21% (adjusted OR 0.79, 95% CI 0.65-0.97), reported Jeffrey T. Kullgren, MD, MS, MPH, of the VA Ann Arbor Healthcare System in Michigan, and colleagues.

Prior to the Choose Wisely behavioral economic intervention, low-value care was used in 20.5% of the control patient-months (7,627 of 37,116). After commitment, this dropped to 16.0% (7,416 of the 46,381 intervention patient-months), the group reported in .

The was started by the American Board of Internal Medicine Foundation in 2012 as a way to reduce unnecessary medical tests, treatments, and procedures. In the trial, clinicians were asked to commit in writing to the Choosing Wisely guidelines for three common medical situations for older patients:

• Avoid using medications other than metformin to in most older adults with diabetes
• Avoid use of in older adults as the first choice for insomnia, agitation, or anxiety
• Don't routinely perform for prostate cancer in older men

"Delivery of low-value services is common and costly, particularly among older adults," Kullgren told 番茄社区. "Our study suggests that clinicians should explore use of effective and scalable interventions like ours that nudge patients and clinicians to achieve greater value while preserving autonomy in decision-making."

"Overuse of low-value care is a worldwide problem in need of solutions that can be scaled and sustained across practice environments," he pointed out. "Our Committing to Choose Wisely behavioral economic intervention engaged primary care clinicians and their older patients to reduce low-value care across three common clinical situations."

Kullgren added that "if this multicomponent template were adapted to target use of low-value care in a range of settings it could reduce patients' exposure to health care that does not improve patient outcomes and can cause unnecessary harms."

After clinicians committed to the recommendations, older patients with diabetes had 85% higher odds of having their glucose lowering medications deintensified (aOR 1.85, 95% CI 1.06-3.24).

On the other hand, the intervention didn't significantly reduce the use of low-value care for any other scenario, including deintensification of sedative-hypnotic medications for insomnia or anxiety (aOR 0.84, 95% CI 0.53-1.33). This was "likely due to the lower power to find relatively small within-cohort intervention effects, although results for the diabetes cohort were sensitive to prespecified analytic decisions," the group said.

"We were surprised that the intervention increased deintensification of hypoglycemic medications for diabetes but not benzodiazepines and sedative-hypnotic medications for insomnia or anxiety," Kullgren said. "We may have seen this divergence because primary care clinicians and their patients may have more difficulty avoiding use of low-value services for symptomatic conditions -- e.g., insomnia and anxiety -- than for generally asymptomatic conditions -- e.g., diabetes."

Conducted at eight primary care clinics between 2017 and 2019, the stepped-wedge cluster randomized clinical trial included 81 primary care clinicians including physicians, nurse practitioners, and physician assistants. The researchers said they selected these three recommendations because they're common in the U.S., involve both clinician and patient input in decision-making, and represent local opportunities for improvement based on administrative data and feedback from health system leaders.

A total of 8,030 older patients (average age 75.1) were included. The diabetes and insomnia or anxiety patients had to be age 65 or older for inclusion, while the prostate cancer screening group had to be at least 75.

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