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Publication Briefs

Barriers to Implementing Choosing Wisely® Recommendations

The Choosing Wisely® (CW) campaign represents a large-scale, evidence-based attempt to identify and raise awareness of low-value healthcare services that are overused in the United States. Since April 2012, the CW campaign has asked national medical specialty societies to each identify five opportunities for reducing overuse of testing, medications, and procedures. While there are data about providers' general attitudes toward the CW campaign, there is no information on providers' views of individual CW recommendations – or on their perceptions of how difficult specific recommendations would be to implement in clinical practice. This study sought to determine whether particular CW recommendations are perceived by primary care providers as difficult to follow, difficult for patients to accept, or both. Investigators surveyed a random sample of 2,000 U.S. primary care physicians (PCPs) in November 2013 and then conducted a second survey of a random sample of 2,500 VA PCPs in October-December 2014. For these surveys, investigators selected 12 recommendations (4 diagnostic testing, 4 screening, and 4 medications), out of the 41 highest-ranking CW recommendations, for inclusion. Participants in the US PCP survey received a $5 incentive in their survey packet; participants in the VA survey were entered into a lottery for a chance to win a $100 gift card.


  • While PCPs found many Choosing Wisely® recommendations easy to follow, they felt that some, especially those for symptomatic conditions, would be difficult for patients to accept.
  • For 4 recommendations about not screening or testing in asymptomatic patients, e.g., avoiding colorectal screening for 10 years in patients with negative colonoscopy, less than 20% of PCPs found the CW recommendations difficult to accept (7%-17%) or difficult for patients to follow (12%-19%).
  • For 5 recommendations about testing or treatment for symptomatic conditions, e.g., limiting the use of antibiotics for sinusitis, avoiding imaging tests for low back pain within the first six weeks, however, there was both variation in reported difficulty to follow (10%-32%) and a high level of reported difficulty for patients to accept (36%-87%).
  • 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.


  • Overcoming PCPs' perceptions of patient acceptability will require approaches beyond routine physician education, feedback, and financial incentives.


  • Concerns aboutresponse rates to study surveys led investigators to conduct them using different modes (mail and web), which may have led to mode effects on responses.

This study was partly funded by HSR&D and OABI, and Dr. Kullgren is supported by an HSR&D Career Development Award. Drs. Kullgren, Fagerlin, Bernstein, and Kerr, and Ms. Klamerus are part of HSR&D's Center for Clinical Management Research (CCMR) in Ann Arbor, MI.

PubMed Logo Zikmund-Fisher BJ, Kullgren JT, Fagerlin A, Klamerus ML, Bernstein SJ, and Kerr EA. Perceived Barriers to Implementing Individual Choosing Wisely® Recommendations in Two National Surveys of Primary Care Providers. Journal of General Internal Medicine. 2016 Sep 6;e-pub ahead of print.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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