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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.
Limitations
Alternative explanations of the observed associations between overtreatment guideline adoption and the rate of recommending targeted services include patient case mix, social desirability bias (ie, underreporting undesirable behaviors, such as the use of services targeted by the guidelines in our study), and recall bias. Although case vignettes with open-ended answer options have high criterion validity (ie, they correlate with actual practice on similar patients),20,21 reported practices may not represent actual physician recommendations to their patients. Furthermore, the proximity of questions about practice patterns and overtreatment guidelines in the questionnaire may have primed respondents to underreport overtreatment.

Concerns about priming and desirability bias suggest that the rates of recommending services targeted by the overtreatment guidelines may be underestimated in this study. Although we obtained a relatively high response rate for a physician survey, and our respondents were similar to the general population (ie, nonrespondents and early and late respondents), the potential for response and selection bias remains.

Lastly, despite efforts to confirm physician eligibility during prescreening, specialty and contact information in the AMA Masterfile may be inaccurate, introducing respondents who fall outside our target sample. A recent comparison of AMA Masterfile physician contact information with other databases found that only 37% were accurate.32
 
CONCLUSIONS
In a national survey, the majority of US internal medicine physicians reported positive attitudes toward overtreatment guidelines in their specialty. However, physicians’ recommendations in guideline-specific standardized patient cases varied. Physicians’ propensity to recommend low-value services was explained in part by physician and practice characteristics. The complexities of physician decision making may explain an observed lack of reduction in the utilization of tests and treatments targeted by such widely disseminated overtreatment guidelines as the Choosing Wisely initiative. Guidelines or similar broad educational interventions by physician organizations are unlikely to reduce physician-level variation in the utilization of low-value services. Furthermore, interventions to reduce low-value care should be evaluated within the context of health system-, practice-, and physician-level factors to avoid unanticipated effects. 

Author Affiliations: Division of General Internal Medicine (KLR, RMW, JAS, JAL), and Leonard Davis Institute of Health Economics (KLR, RMW, JAS, JAL), University of Pennsylvania, Philadelphia, PA; Accreditation Council for Graduate Medical Education (ESH), Chicago, IL; American Board of Internal Medicine (EB), Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center (RMW, JAL), Philadelphia, PA.

Source of Funding: This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the Ruth L. Kirschstein National Research Service Award (NRSA) T32-HP10026. Content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the government.

Author Disclosures: Dr Holmboe receives royalties from a textbook on assessment. The remaining 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 (KLR, ESH, EB, JAS, JAL); acquisition of data (KLR, JAL); analysis and interpretation of data (KLR, ESH, RW, JAS, JAL); drafting of the manuscript (KLR, ESH, EB, JAS, JAL); critical revision of the manuscript for important intellectual content (KLR, ESH, EB, RW, JAL); statistical analysis (KLR, RW, JAL); provision of patients or study materials (KLR, JAS, JAL); obtaining funding (KLR); administrative, technical, or logistic support (KLR, ESH, EB, JAL, JAS); and supervision (JAL).

Address Correspondence to: Kira Ryskina, MD, MS, 12-30 12th Fl, Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104. E-mail: ryskina@mail.med.upenn.edu. 
REFERENCES

1. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-1516. doi: 10.1001/jama.2012.362.

2. Smith MD, Saunders R, Stuckhardt L, McGinnis JM, eds; Committee on the Learning Health Care System in America, Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2012.

3. Yong PL, Saunders RS, Olsen L; Institute of Medicine (US); Roundtable on Evidence-Based Medicine. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington, DC: National Academies Press; 2010.

4. Choosing Wisely: an initiative of the ABIM Foundation. Choosing Wisely website. http://www.choosingwisely.org/. Accessed October 2015.

5. PerryUndem Research/Communication. Unnecessary tests and procedures in the health care system: what physicians say about the problem, the causes, and the solutions. Choosing Wisely website. http://www.choosingwisely.org/wp-content/uploads/2015/04/Final-Choosing-Wisely-Survey-Report.pdf. Published May 1, 2014. Accessed June 2016.

6. Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi: 10.1001/jamainternmed.2015.5441.

7. Mehrotra A, Reid RO, Adams JL, Friedberg MW, McGlynn EA, Hussey PS. Physicians with the least experience have higher cost profiles than do physicians with the most experience. Health Aff (Millwood). 2012;31(11):2453-2463. doi: 10.1377/hlthaff.2011.0252.

8. Gonzales R, Cattamanchi A. Changing clinician behavior when less is more. JAMA Intern Med. 2015;175(12):1921-1922. doi: 10.1001/jamainternmed.2015.5987.

9. Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310(4):380-388. doi: 10.1001/jama.2013.8278.

10. Sirovich BE, Woloshin S, Schwartz LM. Too little? too much? primary care physicians’ views on US health care: a brief report. Arch Intern Med. 2011;171(17):1582-1585. doi: 10.1001/archinternmed.2011.437.

11. Campbell EG, Gruen RL, Mountford J, Miller LG, Cleary PD, Blumenthal D. A national survey of physician-industry relationships. N Engl J Med. 2007;356(17):1742-1750.

12. Brett AS, McCullough LB. Addressing requests by patients for nonbeneficial interventions. JAMA. 2012;307(2):149-150. doi: 10.1001/jama.2011.1999.

13. Neumann PJ, Palmer JA, Nadler E, Fang C, Ubel P. Cancer therapy costs influence treatment: a national survey of oncologists. Health Aff (Millwood). 2010;29(1):196-202. doi: 10.1377/hlthaff.2009.0077.

14. Ubel PA, Berry SR, Nadler E, et al. In a survey, marked inconsistency in how oncologists judged value of high-cost cancer drugs in relation to gains in survival. Health Aff (Millwood). 2012;31(4):709-717. doi: 10.1377/hlthaff.2011.0251.

15. Pollack CE, Mallya G, Polsky D. The impact of consumer-directed health plans and patient socioeconomic status on physician recommendations for colorectal cancer screening. J Gen Intern Med. 2008;23(10):1595-1601. doi: 10.1007/s11606-008-0714-x.

16. Antiel RM, Curlin FA, James KM, Tilburt JC. Physicians’ beliefs and US health care reform—a national survey. N Engl J Med. 2009;361(14):e23. doi: 10.1056/NEJMp0907876.

17. Hurst SA, Hull SC, DuVal G, Danis M. Physicians’ responses to resource constraints. Arch Intern Med. 2005;165(6):639-644.

18. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147(11):795-802.

19. Gruen RL, Campbell EG, Blumenthal D. Public roles of US physicians: community participation, political involvement, and collective advocacy. JAMA. 2006;296(20):2467-2475.

20. Converse L, Barrett K, Rich E, Reschovsky J. Methods of observing variations in physicians’ decisions: the opportunities of clinical vignettes. J Gen Intern Med. 2015;30(suppl 3):S586-S594. doi: 10.1007/s11606-015-3365-8.

21. Peabody JW, Luck J, Glassman P, et al. Measuring the quality of physician practice by using clinical vignettes: a prospective validation study. Ann Intern Med. 2004;141(10):771-780.

22. Dillman DA, Smyth JD, Christian LM, Dillman DA. Internet, Mail, and Mixed-Mode Surveys: The Tailored Design Method. 3rd ed. Hoboken, NJ: Wiley & Sons; 2009.

23. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi: 10.1016/j.jbi.2008.08.010.

24. American Association for Public Opinion Research. Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. 8th ed. Lenexa, KS: American Association for Public Opinion Research; 2015.

25. Morden NE, Colla CH, Sequist TD, Rosenthal MB. Choosing wisely—the politics and economics of labeling low-value services. N Engl J Med. 2014;370(7):589-592. doi: 10.1056/NEJMp1314965.

26. Rich EC, Lake TK, Valenzano CS, Maxfield MM. Paying the doctor: evidence-based decisions at the point-of-care and the role of fee-for-service incentives. J Comp Eff Res. 2013;2(3):235-247. doi: 10.2217/cer.13.26.

27. Judson TJ, Volpp KG, Detsky AS. Harnessing the right combination of extrinsic and intrinsic motivation to change physician behavior. JAMA. 2015;314(21):2233-2234. doi: 10.1001/jama.2015.15015.

28. Khullar D, Chokshi DA, Kocher R, et al. Behavioral economics and physician compensation—promise and challenges. N Engl J Med. 2015;372(24):2281-2283. doi: 10.1056/NEJMp1502312.

29. Reschovsky JD, Rich EC, Lake TK. Factors contributing to variations in physicians’ use of evidence at the point of care: a conceptual model. J Gen Intern Med. 2015;30(suppl 3):555-561.

30. Ubel PA, Asch DA. Creating value in health by understanding and overcoming resistance to de-innovation. Health Aff (Millwood). 2015;34(2):239-244. doi: 10.1377/hlthaff.2014.0983.

31. Huesch MD. A piece of my mind. slippery slopes and landing on your feet. JAMA. 2014;311(12):1203-1204. doi: 10.1001/jama.2014.2067.

32. DesRoches CM, Barrett KA, Harvey BE, et al. The results are only as good as the sample: assessing three national physician sampling frames. J Gen Intern Med. 2015;30(suppl 3):S595-S601. doi: 10.1007/s11606-015-3380-9.  
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