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The American Journal of Managed Care July 2017
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US Internists' Awareness and Use of Overtreatment Guidelines: A National Survey
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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.
Of the 902 potential respondents, 456 (51%) returned a completed survey. No differences between respondents and nonrespondents were observed by age, gender, region of current practice, or practice setting (Table 2). Aside from Asian or Asian American respondents being overrepresented among late responders, there were no differences between early and late responders regarding gender, primary compensation, organization or setting of practice, or self-reported attitudes or satisfaction with medicine as a practice (eAppendix Table 1). Nearly half of the respondents self-characterized primary compensation type as salary with bonus (49.5%), followed by billings (28.1%) and salary only (20.9%), and the majority reported compensation linked to quality of care (62.9%) or productivity (65.1%) (Table 3). Less than 5% of respondents (4.2%) completed residency in 2013. Other characteristics of the respondents’ practices are reported in Table 3.
Respondents’ attitudes toward cost containment are shown in Table 4. Most (88.5%) considered their practice style to be cost conscious. One in 4 (25.1%) reported discomfort discussing costs of care with patients, and 34.7% said they would not feel comfortable making a patient unhappy by denying a request for unnecessary care.
Respondents generally reported high levels of awareness, familiarity, and use of overtreatment guidelines (Table 4). Most (88.5%) reported being familiar with overtreatment guidelines in their specialty, 81.6% reported that the guidelines were useful in their practice, and 79.9% said they felt comfortable bringing up overtreatment guidelines in discussions with patients. However, less than 30% of respondents rated their agreement with these statements as “strong.” Respondents generally reported using overtreatment guidelines in practice with high frequency: 30.9% reported bringing up the guidelines in discussions with patients “frequently” or “always” and 44.2% reported bringing up the guidelines “occasionally.” Approximately 40% of respondents (41.1%) found the guidelines useful in practice “frequently” or “always,” and 42.4% found them “occasionally” useful. When individual responses were combined in the 5-item OGA subscale, the mean scale score was 15.6 (SD = 3.0) and the median 16 (interquartile range [IQR] = 14-18; observed range = 5-22).
In the fully adjusted models, respondents in the middle or top third of OGA subscale scores reported lower rates of recommending a test or treatment targeted by the guidelines for imaging for lower back pain, antibiotics for sinusitis, and cardiac testing for asymptomatic patients compared with the respondents in the bottom third of OGA scores (Figure). 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 EKG testing for asymptomatic patients (11.0%). Physicians with OGA scores in the top third had significantly lower predicted rates of recommending x-rays (–12.0%; 95% CI, –19.4% to –4.5%; P = .002) or MRI (–4.8%; 95% CI, –8.1% to –1.5%; P = .004) for lower back pain and EKG for asymptomatic patients (–10.2%; 95% CI, –18.9% to –1.5%; P = .02) compared with physicians in the bottom third of OGA scores. Physicians with OGA scores in the middle third also had lower predicted rates of recommending antibiotics for sinusitis (–6.9%; 95% CI, –13.0% to –0.8%; P = 0 .03) and EKG for asymptomatic patients (–8.7%; 95% CI, –15.9% to –1.4%; P = .02) compared with physicians in the bottom third of OGA scale scores. The differences in predicted probabilities across the tertiles of OGA scale scores were not significant for cancer screening and imaging as the initial test for patients at a low risk of VTE (Figure).
The association between physician cost consciousness and the percentage of patients recommended for a test or treatment targeted by the guidelines was not consistent: physicians in the top third of cost-consciousness scale scores reported lower rates of prescribing antibiotics for sinusitis and recommending mammography at the end of life, but this association was not observed for the other guidelines (eAppendix Table 2). Other factors associated with recommending services targeted by the guidelines were physician age, practice region, type and setting, practice that treated patients with Medicaid, and satisfaction with medicine as a profession.
In this survey study of physician views of overtreatment guidelines, internal medicine physicians generally reported high levels of awareness, agreement, and use of the guidelines in everyday practice, and their attitudes toward the guidelines were distinct from their attitudes toward cost containment. In addition, physicians who reported greater adoption of overtreatment guidelines recommended fewer tests or treatments targeted by some overtreatment guidelines, even after accounting for their overall cost consciousness. Physicians who reported the highest levels of guideline adoption, however, also reported recommending services targeted by the guidelines in their practice.
Although most physicians generally reported agreement with overtreatment guidelines, only about one-third of the respondents rated their agreement as strong or reported using the guidelines frequently, suggesting considerable ambiguity in their attitudes toward overtreatment. Consistent with this finding, recommended rates of some of the services targeted by the guidelines (eg, x-rays for lower back pain, antibiotics for acute sinusitis) were high even for physicians in the top third of overtreatment guidelines adoption. On the other hand, most respondents (88.5%) assessed their practice style as cost-conscious. These findings suggest that even among physicians who generally had positive attitudes toward cost containment, perceptions of the use of overtreatment guidelines were poor, potentially limiting their impact on physician behavior.
Considering these findings, the lack of a consistent decrease in the use of tests and treatments targeted by the Choosing Wisely campaign is not surprising.6 Of note, although some of the guidelines (eg, cancer screening) categorically recommend against testing when patients meet certain criteria, many guidelines implicitly or explicitly allow for exceptions (eg, for worsening symptoms or prolonged duration of acute sinusitis). These important distinctions were difficult to capture in a survey question that did not ascertain how frequently physicians saw patients that meet the exclusion criteria in the guidelines. Nevertheless, it is unlikely that the variation and high rates of targeted services reported by some of the respondents would be fully explained by variation in case mix.
The 4 services for which we did not observe an association with the OGA scale scores (ie, mammography, colonoscopy, prostate cancer screening, and imaging for VTE) were targeted by guidelines that did not include exceptions in certain patient presentations or for duration of symptoms. This contrasts with the other 4 services that were targeted by guidelines that were worded to include exceptions for certain patient presentations (ie, antibiotics for acute sinusitis, which recommended against ordering antibiotics unless symptoms lasted longer than 7 days or worsen, or for acute lower back pain that is nonspecific). This suggests that guidelines that are more categorically worded may be less likely to influence physician behavior. However, our study was not powered to determine the significance of this pattern. Future research should evaluate the effect of guideline wording on physician behavior.
The 8 tests and treatments evaluated in this study were selected to correspond to recommendations of the Choosing Wisely campaign, which had advantages, including widely disseminated endorsement by multiple professional physician organizations. All recommendations included in the study were proposed by 3 or more specialty groups. The Choosing Wisely campaign leaves the mechanism of endorsement up to the group, emphasizing the grassroots characteristics of the campaign. Specialty groups play a lead role in developing the lists of recommendations, an approach designed to appeal to physician professionalism and establish specialty-endorsed norms of care. However, a review of the recommendations by the first 25 professional groups that participated in the Choosing Wisely program raised concerns that groups may be reluctant to endorse recommendations limiting the use of services that are highly lucrative to the specialty.25 Furthermore, the extent of regional and local professional groups’ involvement in the development of national specialty societies’ Choosing Wisely recommendations is not clearly mandated by the campaign. Hence, regional variation in the propensity of physicians to recommend some services may be less responsive to guidelines endorsed at the national level. Although practice region was significantly associated with only 1 of the 8 services evaluated (EKG for asymptomatic patients), local costs may influence physicians’ recommendations of specific tests and treatments. Future studies should assess how physician perceptions of costs influence their recommendations of services targeted by overtreatment guidelines.
Even in cases in which relatively strong consensus exists regarding the evidence base for optimal care, such as the overtreatment guidelines evaluated in this study, a complex interplay of working environment and personal factors plays a role in physician recommendations.26 Whereas overtreatment guidelines target intrinsic motivation in practicing evidence-based care, policy-level interventions typically focus on extrinsic motivators, such as value-based payments, bundling of payments, or other types of monetary incentives.27,28 Our findings provide empiric evidence supporting the importance of evaluating the effect of intrinsic and extrinsic motivators on physician behavior within the context of practice environment and physician characteristics.
While a mix of incentives could be calibrated to achieve value-based care in theory, in practice, these factors are in flux and conflict with each other at times. Although the current study evaluated the adoption of overtreatment guidelines within the context of environmental (ie, treatment facility), practice, and physician-level factors,29 we were unable to evaluate actual physician practice or compare the relative effect of alternative motivators. Behavioral theory suggests that getting physicians to “de-adopt” practices is more challenging than the adoption of healthcare innovations.30 Moreover, physicians often lack self-awareness of the nonclinical factors that may influence their behavior.31 Although overtreatment guidelines that are evidence based and disseminated in a transparent way may be successful in engaging physicians to consider these issues, the sheer magnitude of factors that influence physician behavior suggests that overtreatment guidelines alone are unlikely to produce a sizeable impact on overuse.

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