title: Discretionary decision making by primary care physicians and the cost of U.S. Health care.
abstract: Efforts to improve the quality and costs of U.S. health care have focused largely on fostering physician adherence to evidence-based guidelines, ignoring the role of clinical judgment in more discretionary settings. We surveyed primary care physicians to assess variability in discretionary decision making and evaluate its relationship to the cost of health care. Physicians in high-spending regions see patients back more frequently and are more likely to recommend screening tests of unproven benefit and discretionary interventions compared with physicians in low-spending regions; however, both appear equally likely to recommend guideline-supported interventions. Greater attention should be paid to the local factors that influence physicians' clinical judgment in discretionary settings.
authors.affiliation: Outcomes Group, Veterans Affairs Medical Center, White River Junction, Vermont, USA. Brenda.Sirovich@dartmouth.edu
authors.forename: Brenda
authors.initials: B
authors.lastname: Sirovich
authors.forename: Patricia M
authors.initials: PM
authors.lastname: Gallagher
authors.forename: David E
authors.initials: DE
authors.lastname: Wennberg
authors.forename: Elliott S
authors.initials: ES
authors.lastname: Fisher
mesh_terms: D003657:Decision Making; D017048:Health Care Costs / Q000706:statistics & numerical data*; D019538:Health Care Surveys; D006296:Health Services / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D006973:Hypertension / Q000628:therapy; D010821:Physicians, Family / Q000523:psychology; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000191:economics*; D014481:United States