Curriculum for patient-centered counseling not linked to reduced low-value testing

1. A standardized patient (SP)-based curriculum in patient-centered techniques for addressing requests for low-value diagnostic tests was not associated with differences in ordering low-value diagnostic tests.

2. The educational intervention did not demonstrate differences in patient-centered techniques in follow-up SP encounters, but was linked to increased SP-rated satisfaction.

Evidence Rating Level: 2 (Good)          

Study Rundown: The “Choosing Wisely” campaign has sought to highlight clinical practices that are often done for incorrect indications and have a substantial cost to health care systems. Efficient education of primary care physicians with regards to the campaign recommendations is an area of interest. One strategy is to use patient-centered approaches to addressing requests for low-value diagnostic tests. This study compared primary care residents who received a training curriculum consisting of two-session standardized patient interactions with feedback on patient-centered techniques to a control group. In blinded follow-up interactions with SPs, the intervention and control residents did not differ in terms of ordering low-value diagnostics, inclusion of patient-centered techniques, or ordering of diagnostic tests for actual patients. The intervention group did have better SP-rated global satisfaction with care.

The described study had a rigorous blinded follow-up period to evaluate the lasting effects of their patient-centered curriculum. However, the results are limited in interpretation due to the number of observed encounters (n = 155) not reaching its goal sample size (n = 190). Moreover, the conclusions are limited to the described intervention, consisting of a short session (approximately 20 minutes) of feedback and training. The follow-up period (mean 140 days following intervention) was also longer than other studies in terms of evaluating effect.

Click to read the study in JAMA Internal Medicine

Relevant Reading: Training Residents to Employ Self-efficacy-enhancing Interviewing Techniques: Randomized Controlled Trial of a Standardized Patient Intervention

In-Depth [randomized control trial]: The described study randomized 61 internal medicine and family medicine residents working at primary care clinics. The intervention arm underwent standardized-patient instruction for two common clinical scenarios (request for MRI for back pain and request for DXA screening) with feedback and instruction on a 6-step approach to patient-centered techniques. Control residents had the same SP encounters but without feedback or instruction following the encounters. Residents then underwent up to three blinded follow-up SP encounters integrated into their primary care clinics 3 to 12 months after the intervention (mean time to 1st follow up 140 days, time to last follow-up 253 days). Encounters (n = 155) were recorded and rated on patient-centered techniques used, and targeted communication strategies utilized.

The residents ordered low-value tests in 26.5% of cases with no difference between arms (adjusted odds ratio 1.07; 95%CI 0.49-2.32). The study arms also did not differ in patient-centered communication (p = 0.9), use of targeted techniques (p = 0.96), or use of diagnostic tests in actual patients (p = 0.27). Standardized patient rated satisfaction was higher for the intervention arm (8.5 vs. 7.8, p = 0.02).

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