Ryskina KL, Shea J, Long J. — University of Pennsylvania
Holmboe ES. — Accreditation Council for Graduate Medical Education
Bernabeo E. — American Board of Internal Medicine
Presented: Society of General Internal Medicine Annual Meeting, April 2015
Background: Overtreatment guidelines that recommend against the use of tests and procedures considered overused in health care have received increasing attention as a tool to reduce health care waste. Physicians’ awareness and use of overtreatment guidelines and factors that influence those views are not well described. This study was a survey of a national sample of internists on their views of overtreatment guidelines, practice related to select guidelines and factors that may influence adoption of overtreatment guidelines such as current practice and training characteristics.
Methods: From July through September 2014, a survey was mailed to a random sample of 1,005 internal medicine physicians selected from the AMA Physician Masterfile who completed residency within the last 10 years. The survey included questions about practice characteristics, training environment, overtreatment guidelines and reported practice in hypothetical patient scenarios. Using factor analysis, a nine-point scale of residency cost-consciousness was developed. Descriptive statistics were used to report physicians’ views on overtreatment guidelines, and multivariable logistic regression was used to test the associations between residency cost-consciousness, reported awareness and use of overtreatment guidelines, and hypothetical practice according to case scenarios.
Results: Of the 441 internists (45%) who returned the survey, 41% were in private practice and 65% were salaried. Mean time from completing residency training was 6.7 years (SD 3.0). Most physicians discuss costs of care with patients: 42% reported discussing costs “occasionally” and 41% “frequently” or “always;” 88% of physicians reported being familiar with overtreatment guidelines in their specialty and 80% reported that the guidelines were useful in their practice. Compared to their current practice, 52% of physicians reported that their practice style in residency was somewhat or a lot less cost conscious while 19% reported that their practice style in residency was somewhat or a lot more cost conscious. There was considerable variation in physician training experiences related to costs of care: The mean residency cost-consciousness score was 27.1 (SD 5.3, range 10–41). In residency, 37% of physicians reported being exposed to teaching about cost-conscious care rarely or never, while 24% reported at least frequent exposure. Compared to the bottom quintile, physicians who scored in the top quintile of residency cost-consciousness were more likely to bring up overtreatment guidelines in discussions with patients (OR=2.9; 95% CI, 1.2–7.2, p=0.02). Physician practice patterns measured using hypothetical scenarios based on current overtreatment guidelines varied; for example, 16% of physicians reported never ordering antibiotics for acute mild-to-moderate sinusitis while 17% reported ordering antibiotics for more than half of their patients with the same presentation. Also, self-reported practice did not correlate with reported use of overtreatment guidelines in practice or residency cost-consciousness.
Conclusions: The majority of U.S. internists discuss costs of care with patients, but many report receiving scant training in this area during residency. Overtreatment guidelines are reported to be a useful tool in patient discussions about overused tests or treatments. However, physician practice measured using hypothetical patient scenarios based on the guidelines does not appear to correlate with training factors or self-perceived use of guidelines.
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