Abstract:
Low-value health services constitute care that in most cases does not improve patient outcomes and can lead to unnecessary harms. Choosing Wisely® (www.choosingwisely.org) is a large-scale, evidence-based campaign to raise awareness of low-value health services that has gained international momentum since being launched in the United States in 2012. However, simple awareness of evidence is often insufficient to change many clinical decisions without strategies that target factors underlying clinicians’ decisions to order these services.

One factor that can drive clinicians to order low-value health services is the context in which they typically make such decisions. Even when clinicians know certain services do not improve population-level outcomes, their decisions to order these services for individual patients are often made quickly in the midst of seeing patients and multi-tasking. These constraints may lead clinicians to rely on heuristics rather than careful deliberation. Further, clinicians can be influenced by patient requests that stem from beliefs that more health care intervention is superior.

A promising solution to this problem that leverages insights from behavioral economics is to ask clinicians to commit to follow specific Choosing Wisely recommendations before patient encounters when their thinking can be more deliberative, and then provide point-of-care supports to promote adherence to these commitments during patient encounters. We recently tested this strategy in 6 primary care clinics and found it led to a significant reduction in orders for potentially low-value services, but may also have increased substitute orders of questionable value. These results highlight not only the great potential of this low-cost, highly exportable strategy to discourage clinicians from ordering low-value services in a range of health care settings, but also the potential for unintended consequences of efforts to reduce low-value care.