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US Internists' Awareness and Use of Overtreatment Guidelines: A National Survey
Kira L. Ryskina, MD, MS; Eric S. Holmboe, MD; Elizabeth Bernabeo, MPH; Rachel M. Werner, MD, PhD; Judy A. Shea, PhD; and Judith A. Long, MD
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US Internists' Awareness and Use of Overtreatment Guidelines: A National Survey

Kira L. Ryskina, MD, MS; Eric S. Holmboe, MD; Elizabeth Bernabeo, MPH; Rachel M. Werner, MD, PhD; Judy A. Shea, PhD; and Judith A. Long, MD
In a national survey, US internists reported high levels of adoption of overtreatment guidelines; despite this fact, they also reported recommending services targeted by the overtreatment guidelines.
Objectives: To assess physician views and perceived adoption of overtreatment guidelines and measure whether adoption of these guidelines influenced the recommendation of a targeted service.

Study Design: A cross-sectional survey mailed from July 2014 to January 2015 to 902 internists who completed residency between 2003 and 2013, randomly selected from the American Medical Association Masterfile.
Methods: Poisson regression was used to model the rate of recommending a targeted service included in the guidelines, based on the level of guideline adoption. 

Results: A total of 456 physicians responded (51% response rate). Most expressed familiarity with overtreatment guidelines (88.5%), a comfort level with discussing these guidelines with patients (79.9%), and described overtreatment guidelines as a useful tool in their practice (81.6%). Physicians in the highest tertile of guideline adoption reported double-digit rates of recommending antibiotics for sinusitis (29.7%), mammogram at end of life (16.5%), and electrocardiogram testing for asymptomatic patients (11.0%). Physicians in the bottom tertile of guideline adoption reported lower rates of recommending x rays (–12.0%; 95% confidence interval [CI], –19.4% to –4.5%; P = .002), magnetic resonance imaging for lower back pain (–4.8%; 95% CI, –8.1% to –1.5%; P = .004), and cardiac testing for asymptomatic patients (–10.2%; 95% CI, –18.9% to –1.5%; P = .02). 

Conclusions: US internal medicine physicians who completed residency between 2003 and 2013 reported high levels of adoption of overtreatment guidelines. Physicians who reported the highest levels of guideline adoption reported recommending services targeted by these guidelines in their practice.
Takeaway Points
We surveyed US internists who graduated residency in 2003 through 2013 about their views of overtreatment guidelines or recommendations against the use of potentially unnecessary tests and procedures. Key findings: 
  • US internists reported high levels of awareness, agreement, and use of overtreatment guidelines. 
  • Even physicians who reported the highest levels of guideline adoption, however, reported recommending services targeted by the guidelines in their practice. 
  • This research highlights the challenge of evidence-based de-implementation of medical tests and treatments in everyday practice.
Overtreatment in medicine, defined as “the waste that comes from subjecting patients to care that, according to sound science and the patients’ own preferences, cannot possibly help them,”1 is estimated to account for nearly 30% of healthcare spending.2 Increasing awareness that diagnostic and therapeutic interventions that physicians order are in some instances unnecessary3 has culminated in widely disseminated overtreatment guidelines, such as the Choosing Wisely campaign.4 Introduced in 2012, Choosing Wisely, an initiative of the American Board of Internal Medicine (ABIM) Foundation, has partnered with Consumer Reports and other medical organizations to provide physicians and patients with lists of potentially avoidable tests, treatments, and procedures.
In a 2014 telephone survey of 600 physicians, 38% of respondents reported having seen or heard about the Choosing Wisely campaign and 81% reported feeling “very comfortable” about “talking to patients about why they should avoid an unnecessary test or procedure.”5 Despite the positive response from practicing physicians, there is little evidence that guidelines alone influence physicians’ ordering decisions. In fact, a recent report using commercial health plan claims data to evaluate the utilization of 7 services targeted by the guidelines failed to detect a meaningful decline in their use.6 However, the study looked at global use of services by health plan beneficiaries without accounting for physician characteristics. For example, a 2012 study of Massachusetts health plan data revealed that physicians with fewer than 10 years’ experience had the highest cost profiles compared with those of more senior physicians.7 Whether physicians’ awareness of overtreatment guidelines reduces the propensity to recommend a targeted service remains unknown.8
To explore possible explanations behind the higher cost profiles of less experienced physicians, we surveyed recent internal medicine residency graduates about their adoption of overtreatment guidelines. Our specific objectives were to: 1) assess physician views of overtreatment guidelines using a novel 5-item scale, 2) estimate self-perceived practices according to select guidelines using hypothetical patient presentations, and 3) measure whether perceived adoption of the guidelines correlates with the likelihood to recommend a targeted service.
Survey Development

A literature review revealed no previously validated instruments evaluating physician attitudes toward overtreatment guidelines. To identify potential items for cognitive testing, we reviewed the literature, combed references from previously reported studies of physician views,9-19 and interviewed experts. Items were developed to assess: 1) physician awareness, agreement with, and use of overtreatment guidelines; 2) self-perceived propensity to recommend a service targeted by the guidelines; and 3) other potential confounders of physician practice identified in prior studies. We conducted 2 cycles of cognitive pilot testing to calibrate the wording to detect differences among physicians about these topics. After initial “think aloud” reviews with local (ie, Pennsylvania) practicing physicians, followed by revisions, we performed broader pilot testing with 100 internal medicine physicians randomly selected from the American Medical Association (AMA) Masterfile.
The final survey included questions about physician demographics, practice characteristics, attitudes known to influence overtreatment, views on overtreatment guidelines (awareness of, agreement with, and usefulness in practice), and self-reported practice in specific clinical scenarios related to the guidelines (eAppendix A [eAppendices available at]). Self-reported practice was assessed using fill-in-the-blank questions asking physicians to estimate the percentage of their patients they recommended for a specific test or treatment. Specifically, respondents were presented with brief descriptions of patient presentations for: 1) low back pain, 2) acute sinusitis, 3) cancer screening with a life expectancy of fewer than 10 years, 4) cardiac screening in asymptomatic routine care, and 5) a low pretest probability of venous thromboembolism (VTE). For example, when asked “For what percentage of patients with acute lower back pain do you order the following?” the respondent would fill in a percent for x-ray, magnetic resonance imaging (MRI), physical therapy, acetaminophen/anti-inflammatories, and opioids. The fill-in-the-blank questionnaire regarding treatment decisions has been shown to have high criterion validity (ie, it correlates with actual practice on similar patients) in prior studies.20,21 To establish content validity, these items were tested by 11 clinical and survey design experts, including practicing primary care clinicians, researchers, and experts in survey design.
Study Sample
Using the AMA Masterfile, we pre-screened 2170 randomly selected internal medicine physicians who completed training within the last 10 years to confirm qualifying specialty, mailing address, and that the physician was actively seeing patients at least 20 hours a week. The final sample included 902 internal medicine physicians who were mailed a paper survey between July 2014 and January 2015 using a modified Dillman method.22 The initial mailing was done by first class mail accompanied by a $2 bill and followed by 2 reminder mailings approximately 6 weeks apart.
Overtreatment Guidelines Adoption Scale
A set of 9 questions comprised the Overtreatment Guidelines Adoption (OGA) Scale, which assessed physicians’ attitudes toward overtreatment guidelines and cost containment in general. Six questions focused on awareness of, agreement with, and perceived usefulness of overtreatment guidelines; comfort denying patient requests for tests or treatments; comfort discussing costs with patients; and self-perception of cost consciousness. These were assessed using a 4-point Likert scale, ranging from strongly disagree to strongly agree. A second set of 3 questions assessed how frequently physicians discussed costs, used the overtreatment guidelines in practice, and found these guidelines to be useful. These were measured using a 5-point Likert scale of frequency.
To summarize overtreatment guidelines, their adoption, and measure physician attitudes toward guidelines separately from general attitudes toward cost containment, we developed 2 subscales: a 5-item OGA subscale and a 4-item cost-containment subscale, using standard factor analysis techniques (eAppendix B). The OGA subscale possible values ranged from 5 to 22; higher scale scores reflected a higher degree of adoption of overtreatment guidelines. The OGA subscale had high internal consistency with Cronbach alpha of 0.82 and rotated loadings of 0.44 to 0.75. Principal components analysis supported a separate cost-containment subscale of 4 questions related to costs (Cronbach alpha, 0.76; rotated loadings, 0.51-0.70).
Outcome Variables
Our main outcome measures were self-reported percentages of patients who were advised to elect 8 services targeted by 5 overtreatment guidelines. The guidelines were selected because they described common clinical scenarios in internal medicine, had been released at least 2 years prior to our survey, and were endorsed by multiple medical groups (Table 1). We asked physicians to fill in the blank with the percentage of their patients they advised to receive a particular service. The options included services targeted by overtreatment guidelines, as well as other management options commonly offered to patients in each clinical context. The following tests and treatments were measured: x-ray and MRI imaging for acute low back pain; antibiotics for mild to moderate sinusitis; breast, prostate, and colon cancer screening for patients with a life expectancy of fewer than 10 years; electrocardiogram (EKG) testing for asymptomatic patients; and computerized tomography scan as the initial test for low-risk patients with possible VTE. Services that were recommended to less than 5% of patients (eg, Papanicolaou test for cervical cancer and stress test for cardiac testing in asymptomatic patients) were excluded from analysis.
Other Variables
Physician demographics, attitudes, reimbursement, and practice characteristics that may confound the relationship between physician views of, and practice according to, overtreatment guidelines, were included in the analysis. Physician demographics included age, gender, and race. Other physician characteristics included practice region, type of practice, compensation type, financial incentives (eg, quality, patient satisfaction, utilization review, productivity), insurance mix (eg, patients with Medicaid insurance), and attitudes (eg, comfort with clinical uncertainty, satisfaction with the practice of medicine in general, malpractice concerns). These items were either drawn from the AMA Masterfile (ie, age and gender) or included questions drawn from previously validated surveys of physicians.
Responses were entered in the REDCap electronic data capture tool (Harvard Catalyst; Boston), hosted at the University of Pennsylvania.23 Ten percent of entries were double-entered with perfect concordance. The data were exported in, and all analyses were conducted, using STATA version 13.0 (StataCorp; College Station, Texas).
We used the American Association for Public Opinion (Research Response Rate 2) definition.24 Nonresponse bias was assessed by comparing respondents with nonrespondents and early to late respondents using the Pearson χ2 test.
The reported percentages of patients who were recommended for a particular test or treatment indicated a discrete number of events over a constrained range (0%-100%) and were positively skewed. Thus, the reported percentages were converted to a count variable based on a denominator of 100 (ie, 10% was converted to 10 out of 100) and modeled using Poisson regression. The independent variable of interest was a trichotomized OGA scale. Other variables in the model included a scale of physician attitudes toward cost containment in general (measured using the cost-containment subscale), physician demographics, practice characteristics, and attitudes previously shown to be associated with overuse (see “Other Variables” section of text). The predicted percentage of patients recommended for a particular test or treatment were estimated. Bootstrapping with 1000 iterations was used to estimate 95% confidence intervals (CIs). This study was reviewed and approved by the University of Pennsylvania Institutional Review Board.

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