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Physician Perceptions of Choosing Wisely and Drivers of Overuse
Carrie H. Colla, PhD; Elizabeth A. Kinsella, BA; Nancy E. Morden, MD, MPH; David J. Meyers, MPH; Meredith B. Rosenthal, PhD; and Thomas D. Sequist, MD, MPH
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Physician Perceptions of Choosing Wisely and Drivers of Overuse

Carrie H. Colla, PhD; Elizabeth A. Kinsella, BA; Nancy E. Morden, MD, MPH; David J. Meyers, MPH; Meredith B. Rosenthal, PhD; and Thomas D. Sequist, MD, MPH
The authors surveyed physicians regarding “Choosing Wisely” and hypothesized drivers of overuse, finding high reported prevalence of hypothesized drivers of overuse and widespread support for cost-consciousness.
The adjusted mean score on the Malpractice Concerns Scale across all respondents was 58.1 (on a scale of 0 to 100), which is slightly lower than the mean 65.4 found by Carrier et al (Table 1).10 Surgeons reported the highest adjusted mean of 63.0, while primary care physicians reported a mean of 57.7 and medical specialties reported a mean of 50.7 (P = .016) (Table 1). Although our recorded scores are lower than those published by others, the trend of surgeons reporting the greatest malpractice concern is consistent with prior studies.10

For the Discomfort With Uncertainty Scale, the mean of all respondents was a 2.7 out of 4. A majority (62%) of all respondents reported that uncertainty involved in providing care was disconcerting; this compares with 56% reported by others.7 There were no significant differences in this score between physician specialties.

After adjusting for covariates, almost all physicians agreed that doctors need to limit unnecessary tests (96.8%), have a responsibility to control costs (92.2%), and should be aware of and adhere to clinical guidelines (97.9%) (Table 3). Approximately one-third felt it unfair to ask physicians to be both cost-conscious and concerned with welfare (33.0%), thought there is too much emphasis on costs (30.7%), try not to think about costs (33.9%), and thought that doctors are too busy to worry about costs (27.8%) (Table 3); these proportions did not differ across specialties. Less than half of respondents (36.9%) reported having a firm understanding of the costs of tests and procedures to the healthcare system. Primary care physicians reported feeling significantly more pressure from patients to order tests and procedures than medical and surgical specialties (68.3%, 58.0%, 55.8%, respectively; P = .024) (Table 3). Primary care physicians were also significantly more likely to report feeling pressure to refer patients to consultants (65.3% vs 34.7% in the medical specialties and 33.7% in the surgical specialties; P <.001) and to feel that the risk of unnecessary tests is important to consider when requesting referrals (58.1% vs 27.9% in the medical specialties and 38.8% in the surgical specialties; P <.001).

DISCUSSION
Overall, we found knowledge of the Choosing Wisely campaign to be limited—but the campaign had been in place for less than 2 years at the time of the survey. Prior work on awareness of clinical practice guidelines showed a broad range in awareness across specialties and services in line with these estimates.14 Primary care physicians were more aware of the campaign than specialists. Further, buy-in to the campaign was mixed, but compared with others, more primary care physicians report “absolutely” viewing the campaign as a legitimate source of guidance—this proportion was still less than half, however. One in 5 primary care physicians reported the campaign has “absolutely” empowered them to reduce their use of unnecessary tests and procedures; however, only a small proportion of specialists expressed this sentiment.

Policy makers, practitioners, and researchers have hypothesized drivers of overuse,15 and many of these factors were prevalent among our physician sample, with more than half of respondents reporting the following: pressure from patients to order tests, ordering tests to reduce risk of malpractice, finding the uncertainty involved in patient care disconcerting, and not understanding of the costs of tests and procedures to the health system. The finding that primary care physicians feel more pressure from patients for tests and procedures suggests that future interventions may need to be specifically oriented toward primary care physicians to equip them with strategies for resisting patient pressure and helping patients to understand that more is not necessarily better. Physicians in this group were remarkably open to the concept of cost-consciousness in medicine and their responsibility in reducing costs. Moreover, most felt decision-support tools would be useful. Working toward e-consults and telemedicine should also aid primary care physicians in gaining confidence at addressing overutilization caused by feeling pressure to complete a consultation.16 Risk of unnecessary testing as a consideration in referral decisions is in line with prior research showing that the most prevalent reason for overriding suggestions to forgo low-value care is recommendation by a specialist.17

Our survey is strengthened by the combination of 3 distinct validated survey tools to measure discomfort with uncertainty, cost-consciousness, and malpractice concerns with other hypothesized drivers of overuse and knowledge of a financial stewardship campaign. Although recent studies have analyzed physician awareness of and attitudes toward Choosing Wisely, as well as physician views regarding healthcare costs,7,18 ours is the first, to our knowledge, to combine pre-validated survey instruments with questions specifically addressing the Choosing Wisely campaign. Our findings link prior literature on physician views of decision making and cost with potential cost-containment strategies informed by the Choosing Wisely effort. 

Our analysis of physician attitudes toward overuse is limited, however, by the fact that we relied on providers’ self-reported perceptions of Choosing Wisely and their attitudes toward overuse. We were thus unable to account for potential social desirability bias or other response biases. Atrius Health physicians also may not be representative of physicians nationwide, they may be more accustomed to initiatives that address healthcare costs. Compared with the ABIM Foundation’s survey of physicians nationwide18; our survey respondents reported being aware of the Choosing Wisely campaign at a significantly higher rate (41% vs 21%). Our study, however, provides insights into the views of physicians practicing within a system at the frontier of payment reform and large-scale integration of care. 

Although we cannot know exactly how representative our respondents are of physicians nationwide, outside of gender and specialty, most of our findings are consistent with previous physician survey studies. We found surgical specialists reported higher malpractice concern than primary care physicians, as previously demonstrated by Carrier et al.10 Also, in our survey, women reported greater discomfort with uncertainty than men—a common trend in the literature.8,9 These findings support the generalizable nature of our sample.

Our analysis also complements the existing literature on physician attitudes and behaviors regarding cost and low-value care while providing new insight. Prior studies identified physicians’ knowledge of clinical guidelines and awareness of costs of tests and procedures as factors affecting the delivery of appropriate, cost-effective care. In these studies, the majority of primary care physicians reported either a lack of knowledge regarding guidelines or forgetting guidelines during patient encounters as barriers to adherence.19 Similarly, clinicians report having a very limited knowledge of costs despite their insistence that cost is an important factor in their decision making.20 Other research has uncovered the complicated trade-offs that physicians face as they strive to care for patients in a thorough yet cost-conscious manner.15 By measuring potential causes of overuse using validated scales, our study quantifies these complex trade-offs and creates a replicable measurement tool that might be applied to a variety of clinicians and tracked over time to measure the impact of efforts aimed at behavior change.

Although widely discussed, the healthcare system has been slow to effectively discourage overuse. Patient and physician knowledge and understanding of which tests are low-value is a necessary first step to reduce overuse of services. This survey provides information on physicians’ knowledge of an informational campaign to identify low-value care and finds communication to primary care physicians has been more successful than communication to specialists. Perhaps most encouragingly, physicians report being ready to consider costs in treatment decisions. Ideally, clinical decision support would be combined with readily available information on price and relative price of tests and procedures to address the significant knowledge gap around healthcare costs expressed by physicians in our survey. This may be facilitated by legislation such as the Massachusetts Medical Price Transparency Law, enacted in January 2014, which guarantees that healthcare cost information be made available to patients and physicians.21

Our results further suggest initiatives aimed at improving physician financial stewardship may benefit from efforts specifically aimed at supporting clinicians in dealing with the uncertainty that comes with conservative management. Physicians may be more willing to forgo or delay expensive low-value care with appropriate support that addresses patient demand, malpractice concerns, and other drivers of overuse. Patient education and shared decision-making tools may reduce perceived patient pressures to do more testing and enhance other activities. Malpractice concerns, on the other hand, require a different set of policy levers and physician protections that are only partially within the control of healthcare systems.

Future Research

Querying physicians about their views of overuse and related concepts is a useful first step for generating testable hypotheses about patterns of overuse and the effectiveness of specific policies to reduce low-value services. These data show hypothesized factors that may be barriers to high-value care, according to physicians’ self-reporting. Thus, the data should inform the focus of future policies and interventions to increase the value of care. Prior analyses suggest a complicated relationship between clinicians’ self-reported decision making and their behaviors; the intricacies of this association require fuller investigation. This information will allow us to determine the most effective levers to reduce overuse.

CONCLUSIONS
Reduction of overuse will require more than just engaging physicians, as the behavior of patients, regulators, and other stakeholders also contributes to the consumption of low-value services. Improving the value in the US healthcare system will require a multi-faceted approach in which all stakeholders’ beliefs and objectives are taken into consideration so that incentives are aligned for the elimination of the use of low-value services across stakeholder groups. 

Author Affiliations: Division of General Internal Medicine, Brigham and Women’s Hospital (EAK), Boston, MA; The Dartmouth Institute for Health Policy and Clinical Practice (CHC, NEM), Hanover, NH; Department of Health Policy and Management (DJM), Harvard School of Public Health (MBR), Boston, MA; Partners Healthcare System (TDS), Boston, MA.

Source of Funding: This work was supported by The Commonwealth Fund [grant number 20130339].

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (CHC, EAK, MBR, TDS); acquisition of data (CHC, EAK, MBR, TDS); analysis and interpretation of data (CHC, DJM, MBR, TDS); drafting of the manuscript (CHC, EAK, DJM); critical revision of the manuscript for important intellectual content (CHC, EAK, NEM, MBR, TDS); statistical analysis (CHC, DJM, TDS); provision of patients or study materials (CHC, EAK); obtaining funding (CHC, TDS); administrative, technical, or logistic support (CHC, EAK); and supervision (CHC, TDS).

Address correspondence to: Carrie H. Colla, PhD, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, 35 Centerra Pkwy, Lebanon, NH 03766. E-mail: Carrie.H.Colla@Dartmouth.edu. 
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