Choosing Wisely intervention decreases low-value care for older patients

Key takeaways:

• An intervention steeped in behavioral economics reduced low-value services for older adults.
• For example, the intervention increased the odds of deintensification of hypoglycemic medications for diabetes.

A behavioral economics intervention was associated with reduced low-value care among older adults, according to a randomized study published in JAMA Internal Medicine.

According to Jeffrey Kullgren, MS, MD, MPH, an associate professor in the department of internal medicine at the University of Michigan School of Medicine, and colleagues, low-value care — care that does not improve health outcomes — is costly and common among older adults.

“One evidence-based effort to raise awareness of low-value services is the Choosing Wisely campaign,” they wrote. “However, awareness of evidence is often insufficient to change clinical decisions.”

In a stepped-wedge cluster randomized trial, the researchers tested the effectiveness of an intervention based on the Choosing Wisely campaign to reduce low-value care among older patients with diabetes, anxiety or insomnia and who were eligible for prostate screening.

The intervention — which took place from Dec. 12, 2017, through Sept. 4, 2019 — included 81 primary care providers and 8,030 older adult patients (mean age, 75 years; 50.8% men) across eight primary care clinics. Within each clinic, clinicians were invited to participate, and those who accepted committed in writing to follow three Choosing Wisely recommendations:

• use medications other than metformin to achieve an HbA1c level less than 7% in most older adults with diabetes;
• refrain from using benzodiazepines or sedative-hypnotics in older adults as the first choice for agitation, insomnia, or anxiety; and
• refrain from routinely performing prostate-specific antigen-based screening for prostate cancer in older men.

Clinicians then had their photographs displayed in clinical public areas and examination rooms to remind them of their commitment and received weekly emails with alternatives to low-value care.

The study’s primary outcome was patient-months with low-value care “because use of low-value care can be dynamic over time for individual patients, particularly for management of chronic conditions,” the researchers said.

A low-value service was used in 20.5% of the 37,116 patient-months during the control period and in 16% of the 46,381 patient-months in the intervention period (adjusted OR = 0.79; 95% CI, 0.65-0.97).

The intervention also increased the odds of deintensification of hypoglycemic medications for diabetes (aOR = 1.85; 95% CI, 1.06-3.24).

“This increased deintensification is important because overtreatment of diabetes is common among older adults and infrequently addressed despite its potential for harms,” the researchers explained.

However, the intervention did not impact low-value medications for insomnia or anxiety.

“This finding could indicate the greater difficulty that primary care clinicians and patients may have in avoiding use of low-value services for symptomatic conditions relative to asymptomatic conditions,” Kullgren and colleagues suggested.

They concluded that the use of interventions “that nudge patients and clinicians to achieve greater value while preserving autonomy in decision-making should be explored broadly.”