Are You Willing to Commit?

For the past two years, Jeffrey Kullgren, MD, a research scientist from the VA Center for Clinical Management Research and assistant professor at University of Michigan Medical School, has been studying the effectiveness of using a pre-commitment strategy, which involves asking physicians to commit themselves to not order tests or treatments that are unwarranted for specific conditions, in supporting the implementation of Choosing Wisely® recommendations.

Funded by the Robert Wood Johnson Foundation, Dr. Kullgren’s first study ran from fall 2014 to spring 2015 and focused on pre-commitment among primary care providers at IHA, a large multispecialty group practice in Michigan. The intervention involved educating clinicians on the campaign followed by an option to commit to three Choosing Wisely recommendations: avoiding imaging for low back pain with no red flags, avoiding imaging for uncomplicated headache and not prescribing antibiotics for acute sinusitis. Participating physicians received reminders about their commitment and a Consumer Reports patient brochure right before they met with a patient with one of the pre-identified conditions.

“The goal is to change the environment in which clinicians make decisions,” Dr. Kullgren said. “The handout makes it easier to have conversations about services of questionable value and address patients’ concerns. We also sent clinicians weekly emails that linked to online communication skills-building modules to help them better navigate difficult conversations with patients.”

Dr. Kullgren intends to publish full results from the study in the future, and initial findings show some promise that the intervention led to changes in ordering behavior and improved clinician communication with patients.

“It showed that we can deliver this in a large private practice, which is similar to clinical environments around the country,” he said. “We wanted to demonstrate the acceptability and feasibility of this in real-world practice.”

Dr. Kullgren recently received a grant from the Donaghue Foundation for another study that he plans to launch next year. Currently in the planning stages, the project will engage primary care and specialist physicians from IHA and the University of Michigan Health System. Clinicians participating in the project will select which Choosing Wisely recommendations to focus on, informed by ordering data and clinician conversations about which recommendations to prioritize. The pre-commitment will take place in a group of peers, and posters will be hung to highlight the group’s commitment.

To explore ways for patients to be better informed and active participants in conversations aimed at reducing unnecessary care, the project proposes to also share educational materials with patients in advance of their appointments. Dr. Kullgren said the goal is not only to track quantitative results to compare ordering behavior before and after the intervention, but also to collect qualitative data on how the intervention might change clinicians’ and patients’ experiences.

“Clinicians were trained to deliver many tests and procedures that are now identified through the Choosing Wisely campaign as low value,” Dr. Kullgren said. “We want to help those clinicians do the right thing consistently while preserving their autonomy. We’re hoping to create a blueprint that other health systems can use to engage in similar work to address overuse.”