Internal Medicine Department, Hôpital de la Tour and University of Geneva, 1217, Geneva, Switzerland.
Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.
J Gen Intern Med. 2021 Sep;36(9):2672-2677. doi: 10.1007/s11606-021-06624-9. Epub 2021 Feb 8.
The impact of the Choosing Wisely (CW) campaign is debated as recommendations alone may not modify physician behavior.
The aim of this study was to assess whether behavioral interventions with physician assessment and feedback during quality circles (QCs) could reduce low-value services.
Pre-post quality improvement intervention with a parallel comparison group involving outpatients followed in a Swiss-managed care network, including 700 general physicians (GPs) and 150,000 adult patients.
Interventions included performance feedback about low-value activities and comparison with peers during QCs. We assessed individual physician behavior and healthcare use from laboratory and insurance claims files between August 1, 2016, and October 31, 2018.
Main outcomes were the change in prescription of three low-value services 6 months before and 6 months after each intervention: measurement of prostate-specific antigen (PSA) and prescription rates of proton pump inhibitors (PPIs) and statins.
Among primary care practices, a QC intervention with physician feedback and peer comparison resulted in lower rates of PPI prescription (pre-post mean prescriptions per GP 25.5 ± 23.7 vs 22.9 ± 21.4, p value<0.01; coefficient of variation (Cov) 93.0% vs 91.0%, p=0.49), PSA measurement (6.5 ± 8.7 vs 5.3 ± 6.9 tests per GP, p<0.01; Cov 133.5% vs 130.7%, p=0.84), as well as statins (6.1 ± 6.8 vs 5.6 ± 5.4 prescriptions per GP, p<0.01; Cov 111.5% vs 96.4%, p=0.21). Changes in prescription of low-value services among GPs who did not attend QCs were not statistically significant over this time period.
Our results demonstrate a modest but statistically significant effect of QCs with educative feedback in reducing low-value services in outpatients with low impact on coefficient of variation. Limiting overuse in medicine is very challenging and dedicated discussion and real-time review of actionable data may help.
仅仅提出建议可能无法改变医生的行为，因此“明智选择”（Choosing Wisely）运动的影响存在争议。
本研究旨在评估在质量圈（QC）中进行医生评估和反馈的行为干预是否可以减少低价值服务。
这是一项在瑞士管理式医疗网络中进行的、涉及 700 名全科医生（GP）和 15 万名成年患者的门诊患者的、前瞻性质量改进干预研究，其中包括一个平行比较组。
干预措施包括在 QC 期间提供有关低价值活动的绩效反馈和与同行进行比较。我们在 2016 年 8 月 1 日至 2018 年 10 月 31 日期间，从实验室和保险索赔记录中评估了每位医生的行为和医疗保健使用情况。
主要结局是在每次干预前后 6 个月内，三种低价值服务的处方变化情况：前列腺特异性抗原（PSA）检测和质子泵抑制剂（PPI）和他汀类药物的处方率。
在初级保健实践中，一项包含医生反馈和同行比较的 QC 干预措施导致 PPI 处方率降低（每个 GP 的预干预后处方量为 25.5 ± 23.7 比 22.9 ± 21.4，p 值<0.01；变异系数（Cov）为 93.0%比 91.0%，p=0.49）、PSA 检测（每个 GP 的 6.5 ± 8.7 比 5.3 ± 6.9 次，p<0.01；Cov 为 133.5%比 130.7%，p=0.84）和他汀类药物（每个 GP 的 6.1 ± 6.8 比 5.6 ± 5.4 个处方，p<0.01；Cov 为 111.5%比 96.4%，p=0.21）。在此期间，未参加 QC 的 GP 的低价值服务处方变化在统计学上没有显著变化。
我们的结果表明，QC 结合教育性反馈在减少低价值服务方面具有适度但统计学上显著的效果，对变异系数的影响很小。限制医学上的过度使用非常具有挑战性，而专门的讨论和实时审查可操作数据可能会有所帮助。
