Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial.

BACKGROUND: Little is known about how to discourage clinicians from ordering low-value services. Our objective was to test whether clinicians committing their future selves (ie, precommitting) to follow Choosing Wisely recommendations with decision supports could decrease potentially low-value orders. METHODS: We conducted a 12-month stepped wedge cluster randomised trial among 45 primary care physicians and advanced practice providers in six adult primary care clinics of a US community group practice.Clinicians were invited to precommit to Choosing Wisely recommendations against imaging for uncomplicated low back pain, imaging for uncomplicated headaches and unnecessary antibiotics for acute sinusitis. Clinicians who precommitted received 1-6 months of point-of-care precommitment reminders as well as patient education handouts and weekly emails with resources to support communication about low-value services.The primary outcome was the difference between control and intervention period percentages of visits with potentially low-value orders. Secondary outcomes were differences between control and intervention period percentages of visits with possible alternate orders, and differences between control and 3-month postintervention follow-up period percentages of visits with potentially low-value orders. RESULTS: The intervention was not associated with a change in the percentage of visits with potentially low-value orders overall, for headaches or for acute sinusitis, but was associated with a 1.7% overall increase in alternate orders (p=0.01). For low back pain, the intervention was associated with a 1.2% decrease in the percentage of visits with potentially low-value orders (p=0.001) and a 1.9% increase in the percentage of visits with alternate orders (p=0.007). No changes were sustained in follow-up. CONCLUSION: Clinician precommitment to follow Choosing Wisely recommendations was associated with a small, unsustained decrease in potentially low-value orders for only one of three targeted conditions and may have increased alternate orders. TRIAL REGISTRATION NUMBER: NCT02247050; Pre-results.

Transcranial magnetic stimulation over MT/MST fails to impair judgments of implied motion.

The medial temporal and medial superior temporal cortex (MT/MST) is involved in the processing of visual motion, and fMRI experiments indicate that there is greater activation when subjects view static images that imply motion than when they view images that do not imply motion at all. We applied transcranial magnetic stimulation (TMS) to MT/MST in order to assess the functional necessity of this region for the processing of implied motion represented in static images. Area MT/MST was localized by the use of a TMS-induced misperception of visual motion, and its location was verified through the monitored completion of a motion discrimination task. We controlled for possible impairments in general visual processing by having subjects perform an object categorization task with and without TMS. Although MT/MST stimulation impaired performance in a motion discrimination task (and vertex stimulation did not), there was no difference in performance between the two forms of stimulation in the implied motion discrimination task. MT/MST stimulation did, however, improve subjects' performance in the object categorization task. These results indicate that, within 150 msec of stimulus presentation, MT/MST is not directly involved in the visual processing of static images in which motion is implied. The results do, however, confirm previous findings that disruption of MT/MST may improve efficiency in more ventral visual processing streams.

Normal attention orienting but abnormal stimulus alerting and conflict effect in combined subtype of ADHD.

Recent pharmacological studies in animals and neuroimaging studies in normal humans suggest that the spatial and nonspatial cues in tasks measuring reflexive attention may be modulated by different neurotransmitter systems. The efficiency with which attention is oriented to explicit spatial cues may be altered by manipulating levels of brain acetylcholine, whereas reactions to nonspatial cues may be influenced by altering brain noradrenaline levels but not acetylcholine levels. In humans, however, previous attention studies have implicated dopamine when either explicit or implicit cueing is used. Some of the differences between animal and human work may be due to inadequate testing of nonspatial cues. To remedy this, we tested adult humans with ADHD that were primarily inattentive (ADHD/I) or combined inattentive/hyperactive (ADHD/C) and controls with the Attention Network Task that assesses both reflexive and voluntary attention and explicitly tests nonspatial cueing. Our results showed that spatial orienting in both subtypes was no different than controls. However, ADHD/C but not ADHD/I subjects had significantly slowed response times to nonspatial cues and cues with spatial conflict. Stimulant medication in a subset of ADHD/C subjects reduced these deficits to control levels. Based on these results, we conclude that ADHD/C subjects orient the focus of their attention normally but are impaired in their reactions both to abrupt visual cues and those that contain conflicting spatial cues.