WBB's Thought Leadership

Choosing Wisely: Randomized Trial Shows Little Effect

October 25

Randomized field trial showed no significant reduction in low-value care at primary care level, and no changes to imaging and antibiotic orders were sustained in a follow-up review.

“Choosing Wisely” is an initiative by the American Board of Internal Medicine (ABIM). The authors found no change in the percentage of low-value orders for sinusitis and headache, but saw a 1.7% overall increase in alternate orders. For low back pain, there was a 1.2% decrease in potentially low-value orders, and a 1.9% increase in the percentage of visits with alternate orders.

WBB Take: Reducing low-value services is a key component of reducing waste in the healthcare system, but early research results show little effect of the flagship intervention – the ABIM “Choosing Wisely” initiative. Reducing low-value imaging orders may have a substantial effect on cost and risk to patients, while curtailing unnecessary antibiotic prescriptions can reduce cost and the advance of resistant strains.
Further research is needed to identify pathways and order sets that can be influenced without increasing risk of under-treating, as well as to identify causes of lack of adoption and sustainment. To identify opportunities and barriers, a team approach is needed, in which clinicians, quality improvement experts, and patients work together towards a common goal of reducing waste and risk.


Cited by Matthew Loxton
Excerpt: “Little is known about how to discourage clinicians from ordering low-value services. Our objective was to test whether clinicians committing their future selves (ie, precommitting) to follow Choosing Wisely recommendations with decision supports could decrease potentially low-value orders.”
“We conducted a 12-month stepped wedge cluster randomised trial among 45 primary care physicians and advanced practice providers in six adult primary care clinics of a US community group practice. Clinicians were invited to precommit to Choosing Wisely recommendations against imaging for uncomplicated low back pain, imaging for uncomplicated headaches and unnecessary antibiotics for acute sinusitis.”
“Clinicians who precommitted received 1–6 months of point-of-care precommitment reminders as well as patient education handouts and weekly emails with resources to support communication about low-value services. The primary outcome was the difference between control and intervention period percentages of visits with potentially low-value orders. Secondary outcomes were differences between control and intervention period percentages of visits with possible alternate orders, and differences between control and 3-month postintervention follow-up period percentages of visits with potentially low-value orders.”
“The intervention was not associated with a change in the percentage of visits with potentially low-value orders overall, for headaches or for acute sinusitis, but was associated with a 1.7% overall increase in alternate orders (p=0.01). For low back pain, the intervention was associated with a 1.2% decrease in the percentage of visits with potentially low-value orders (p=0.001) and a 1.9% increase in the percentage of visits with alternate orders (p=0.007). No changes were sustained in follow-up.”

Source: BMJ Quality & Safety


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