Natural Experiment: "Gentle Nudge" Intervention, Eliminating Phone Call Requirement (LBP-ED)

Back pain costs the U.S. over $100 billion annually, and much of this spending is wasteful due to the overuse of advanced diagnostic imaging. Despite prominent clinical guidelines and the nationally recognized Choosing Wisely campaign discouraging use of costly and low value imaging, magnetic resonance imaging (MRI) and computed tomography (CT) studies remain frequently overused. Real-time electronic clinical decision support (CDS) at the point of care has been increasingly emphasized as an important strategy to improve the value of back pain management; however, studies suggest that CDS at best only modestly influences practice patterns. The aim is to implement a behavioral economic-based intervention in the ED to promote the use of CDS system.

Study Overview

• Status: Completed
• Conditions: MRI; Back Pain; CT Scan; X-rays; Clinical Decision Support Tool
• Intervention / Treatment: Behavioral: Gentle Nudge; Behavioral: Usual Standard Procedure

Detailed Description

Despite prominent clinical guidelines and the nationally recognized Choosing Wisely campaign discouraging use of costly and low value imaging, magnetic resonance imaging (MRI) and computed tomography (CT) studies remain frequently overused. Few studies have rigorously investigated the causes of CDS' limited influence on care as well as interventions to enhance CDS' impact on reducing low value imaging. The implementation of CDS to reduce low value MRI and CT imaging studies for back pain at a large safety net health system was monitored. The CDS systems was integrated into the electronic health record system. Clinicians answered several questions and select from a list of basic imaging indications and CDS provides an American College of Radiology Appropriateness Criteria score. Appropriate scores ranged from 7-9, borderline scores ranging from 4-6, and inappropriate scores ranging from 1-3 (clinicians are encouraged to cancel inappropriate orders).

Electronic order data on imaging studies was pulled using CPT billable data and imaging studies were categorized as appropriate, canceled, changed, and unscored orders. Early observation of CDS implementation revealed that LAC+USC Medical Center (one of 16 sites) had high percentages of unscored orders. At this intervention site, a "nudge" grounded in behavioral economic theory (nudge=gentle incentive, preserving freedom of choice) was provided where clinicians ordering medium or high scoring studies could bypass the usual mandatory phone call to radiology. This natural experiment was evaluated using a quasi-experimental difference-in-differences (DinD) analysis to measure whether high scores increased and unscored studies decreased at the intervention site vs. 15 control sites over time. Generalized linear regression models were used that accounted for clustering by practice site and adjusting for patient and clinician characteristics.

• Study Type: Interventional
• Enrollment (Actual): 20000
• Phase: Not Applicable

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Adults with Lower Back Pain receiving treatment at Los Angeles Department of Health Services Facility (LAC-DHS)
• Adults whose physicians order Imaging Studies (CT SCANs and MRIs)

Exclusion Criteria:

• Non-LAC-DHS patients
• Patient without Lower Back Pain

Study Plan

How is the study designed?

Design Details

• Primary Purpose: HEALTH_SERVICES_RESEARCH
• Allocation: NON_RANDOMIZED
• Interventional Model: PARALLEL
• Masking: SINGLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: Intervention Group; A "nudge" grounded in behavioral economic theory (nudge=gentle incentive, preserving freedom of choice)	Behavioral: Gentle Nudge; Clinicians ordering medium or high scoring imaging studies could bypass the usual mandatory phone call to radiology.
PLACEBO_COMPARATOR: Control; No "nudge"	Behavioral: Usual Standard Procedure; Clinicians ordering imaging studies required mandatory phone to radiology

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percentage of Unscored Imaging Orders	Change in the percentage of Unscored Imaging Orders	6 months from the date of intervention implementation

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percentage of Appropriate, Borderline and Inappropriate Imaging Orders	Change in the percentage of Appropriateness, Borderline and Inappropriate Imaging Orders	6 months from the date of intervention implementation

Collaborators and Investigators

• Sponsor: University of California, Los Angeles
• Collaborators: LAC+USC Medical Center; Los Angeles Department of Health Services; American Board of Internal Medicine

Study record dates

Study Major Dates

• Study Start (ACTUAL): February 1, 2015
• Primary Completion (ACTUAL): January 1, 2016
• Study Completion (ACTUAL): February 1, 2016

Study Registration Dates

• First Submitted: October 12, 2017
• First Submitted That Met QC Criteria: December 20, 2017
• First Posted (ACTUAL): December 22, 2017

Study Record Updates

• Last Update Posted (ACTUAL): December 22, 2017
• Last Update Submitted That Met QC Criteria: December 20, 2017
• Last Verified: December 1, 2017

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Back Pain
• Other Study ID Numbers: UCLA IRB#16-000932-002

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No