Perceived Barriers to Implementing Individual Choosing Wisely®Recommendations in Two National Surveys of Primary Care Providers.
BACKGROUND
While some research has examined general attitudes about efforts to reduce overutilization of services, such as the Choosing Wisely®(CW) initiative, little data exists regarding primary care providers' attitudes regarding individual recommendations.


OBJECTIVE
We sought to identify whether particular CW recommendations were perceived by primary care providers as difficult to follow, difficult for patients to accept, or both.


METHODS
Two national surveys, one by mail to a random sample of 2000 U.S. primary care physicians in November 2013, and the second electronically to a random sample of 2500 VA primary care providers (PCPs) in October-December 2014.


METHODS
A total of 603 U.S. primary care physicians and 1173 VA primary care providers. Response rates were 34 and 48 %, respectively.


METHODS
PCP ratings of whether 12 CW recommendations for screening, testing and treatments applicable to adult primary care were difficult to follow and difficult for patients to accept; and ratings of potential barriers to reducing overutilization.


RESULTS
For four recommendations regarding not screening or testing in asymptomatic patients, less than 20 % of PCPs found the CW recommendations difficult to accept (range 7.2-16.6 %) or difficult for patients to follow (12.2-19.3 %). For five recommendations regarding testing or treatment for symptomatic conditions, however, there was both variation in reported difficulty to follow (9.8-32 %) and a high level of reported difficulty for patients to accept (35.7-87.1 %). The most frequently reported barriers to reducing overuse included malpractice concern, patient requests for services, lack of time for shared decision making, and the number of tests recommended by specialists.


CONCLUSIONS
While PCPs found many CW recommendations easy to follow, they felt that some, especially those for symptomatic conditions, would be difficult for patients to accept. Overcoming PCPs' perceptions of patient acceptability will require approaches beyond routine physician education, feedback and financial incentives.
Department of Health Behavior and Health Education, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA. bzikmund@umich.edu.|Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA. bzikmund@umich.edu.|Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. bzikmund@umich.edu.|Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA. bzikmund@umich.edu.
Brian J
BJ
Zikmund-Fisher
Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.|Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.|Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA.|VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
Jeffrey T
JT
Kullgren
Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.|Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.|Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA.|VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.|Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA.
Angela
A
Fagerlin
VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
Mandi L
ML
Klamerus
Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.|Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.|VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
Steven J
SJ
Bernstein
Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.|Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.|VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
Eve A
EA
Kerr
D001291:Attitude of Health Personnel; D003695:Delivery of Health Care / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics; D000069342:Medical Overuse / Q000517:prevention & control*; D058007:Physicians, Primary Care / Q000523:psychology*; D011320:Primary Health Care / Q000191:economics / Q000458:organization & administration; D011795:Surveys and Questionnaires; D019564:Unnecessary Procedures