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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.
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
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: 

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