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PCPs report patient acceptance as a barrier to following Choosing Wisely recommendations

While most primary care physicians followed the majority of Choosing Wisely recommendations, some did not follow certain recommendations for symptomatic conditions, according to recently published findings.

“Very few survey respondents either perceived difficulty in following that recommendation [or] anticipated that patients would find it difficult to accept,” Brian J. Zikmund-Fisher, PhD, in the Department of Internal Medicine at the University of Michigan, and colleagues wrote. “At the same time, however, a majority of those same providers anticipated major challenges in getting patients to accept certain other [Choosing Wisely] CW recommendations, such as not prescribing antibiotics for sinusitis and avoiding imaging for lower back pain within the first 6 weeks.”

Some research has examined general attitudes about the CW recommendations, which were created to reduce the overutilization of health care services, the researchers wrote. However, there is not enough data about physician’s attitudes on individual recommendations.

To identify whether certain recommendations were perceived as either difficult for the physician to follow or for the patient to accept, Zikmund-Fisher and colleagues performed two national randomized surveys. They distributed one survey by mail to 2,000 primary care physicians in the United States in 2013 and the second electronically to 2,500 Veterans Affairs (VA) physicians in 2014. Responding to the survey were 603 general physicians and 1,173 VA providers. The researchers measured whether the 12 CW recommendations were perceived as difficult for the physician to follow or for the patient to accept, as well as ratings of potential barriers to reduce health care overutilization.

They found less than 20% of physicians found the recommendations difficult to accept (range, 7.2% to 16.6%) or difficult for the patients to follow (12.2% to19.3%). For five recommendations about testing or treatment for symptomatic conditions, there was variation in reported difficulty for physicians to follow (9.8% to 32%) and reported difficulty for the patients to accept (35.7% to 87.1%). These recommendations include the following:

• do not routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for 7 or more days or symptoms worsen after initial improvement;
• do not perform imaging for lower back pain within the first 6 weeks unless red flags are present;
• do not use sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium;
• do not obtain a CT or MRI in the evaluation of simple syncope or in a normal neurological examination; and
• do not use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

In addition, the most frequently reported barriers to reducing overutilization included concern of malpractice, patient requests for services, lack of time for shared decision-making and specialists recommending tests.

“[The] cross-recommendation variations in provider attitudes that we document imply that implementation efforts will need to be tailored to the specific barriers in implementing each CW recommendation,” the researchers wrote. “Such tailoring may be critical in producing meaningful reductions in overuse of low-value health care services.” – by Will Offit

Disclosure: The researchers report no relevant financial disclosures.