A few ‘bad apple’ doctors are not Choosing Wisely: study

By Michael Woodhead

16 Oct 2018

With initiatives such as Choosing Wisely and the RACP’s Evolve program gaining momentum, Canadian researchers say it may be better to focus interventions on the small minority of doctors who account for a disproportionate number of ‘low value’ tests and treatments.

In a study of inappropriate test ordering by physicians in Ontario they found that one in six of doctors were responsible for almost 40% of low value screening tests such as repeat DXA scans and x-rays.

Published in JAMA Network Open, their evaluation covered the ordering of four types of low value test by 2394 primary care physicians.  The researchers measured four ordering behaviours deemed to be low value: repeated DXA scans for patients with a prior DXA scan in the past two years; ECGs for low risk patients; chest x-rays for patients at low risk for cardiopulmonary disease and Pap tests for women under 21.

In their analysis the most frequent users represented 18.4% of the total group of physicians, who between them ordered 39.2% of low value tests.

Physicians who were male, domestic medical graduates, and were an average of 25 years from medical school graduation had significantly greater odds of being frequent users. In contrast, doctors working in a capitation payment model were less likely to be frequent users than those working in a medical group based on fee-for-service payments.

“The results demonstrate that, while most physicians exhibit infrequent or isolated frequent use of low-value screening tests, there is a minority of physicians who are responsible for a large proportion of all low-value testing ordered,” the researchers write.

They note that the results of Choosing Wisely campaigns have been marginal , and say the findings raise doubts about broadly-implemented-based interventions such as decision-support software and audits being imposed on all physicians in an effort to reduce overinvestigation and overtreatment.

“Most physicians do not order low-value care frequently enough for interventions to make a significant difference in ordering practice,” they note.

“Worse, the increased administrative burden that goes along with most interventions, such as decision support tools, may lead to increased frustration and physician burnout.”

Instead, they suggest that activities be tailored, with high-intensity interventions such as academic detailing focused on the minority of high-ordering physicians, and a lower-intensity intervention (eg, broad awareness and education campaigns) aimed at physicians who order low-value care infrequently.

“Such an approach would avoid exposing physicians who infrequently order low-value care to potentially burdensome quality improvement initiatives for which the marginal benefit may be limited and may be more cost-effective,” they conclude.

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