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2015 HSR&D/QUERI National Conference Abstract

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3059 — VHA Provider Attitudes about Choosing Wisely Recommendations

Klamerus ML, VA Center for Clinical Management Research; Fagerlin A, VA Center for Clinical Management Research; University of Michigan; Zikmund-Fisher BJ, University of Michigan; Kullgren J, VA Center for Clinical Management Research; University of Michigan; Bernstein SJ, VA Center for Clinical Management Research; University of Michigan; Prenovost K, VA Center for Clinical Management Research; Kerr EA, VA Center for Clinical Management Research; University of Michigan;

Objectives:
The Choosing Wisely (CW) campaign was initiated in 2011 to spark conversations between providers and patients about limiting care that patients don't need and may not prefer. CW includes over 350 evidence-based recommendations, from 70 medical societies, to address the potential overuse and misuse of testing, procedures, and medications. We examined VHA primary care providers' (PCPs) attitudes regarding specific CW recommendations to evaluate the range of recommendation acceptability. We also assessed reported barriers to decreasing use of unnecessary services.

Methods:
We identified all non-resident VHA PCPs (physicians, nurse practitioners, and physician assistants) with > = 1 day of patient care per week. A national random sample of 2,500 PCPs received an anonymous, online survey. Survey questions included barriers to implementing recommendations to limit overuse and acceptability of 12 CW recommendations common in primary care. For each recommendation, PCPs were asked: How easy or difficult would it be for: 1) YOU to follow; 2) MOST PATIENTS to accept.

Results:
48% (N = 1,173) returned a completed survey. Providers found some recommendations much more difficult to follow than others. For example, 34% rated not imaging for suspected pulmonary embolism without moderate or high pre-test probability as difficult to follow, while only 7% rated not screening for carotid artery stenosis in asymptomatic adults as difficult. Similarly, PCPs felt some recommendations would be more difficult for patients to accept than others. For example, 78% felt patients would find limiting the use of antibiotics for sinusitis as difficult to accept, while only 12% felt patients would find not repeating colorectal cancer screening after a negative high-quality colonoscopy as difficult. Over 50% rated "Concern about patient dissatisfaction if they don't receive a service" as a major barrier to implementing recommendations; this barrier was significantly associated (p < .01) with the CW recommendations that providers rated as most difficult to follow.

Implications:
Responses documented considerable variation (for both provider difficulty to follow and perceived patient acceptability) across specific CW recommendations.

Impacts:
It is critical to reduce the use of unnecessary and potentially harmful services. Understanding which CW recommendations are the most difficult to follow and why can help VHA more effectively decrease the overuse of low-value care.