Introduction

Physicians vary widely in how they treat some health conditions, despite strong evidence favoring certain treatments over others. We examined physicians’ perspectives on factors that support or hinder evidence-based decisions and the implications for delivery systems, payers, and policymakers.

Methods

We used Choosing Wisely^® recommendations to create four clinical vignettes for common types of decisions. We conducted semi-structured interviews with 36 specialists to identify factors that support or hinder evidence-based decisions. We examined these factors using a conceptual framework that includes six levels: patients, physicians, practice sites, organizations, networks and hospital affiliations, and the local market. In this model, population characteristics and payer and regulatory factors interact to influence decisions.

Results

Patient openness to behavior modification and expectations, facilitated and hindered physicians in making evidence-based recommendations. Physicians’ communication skills were the most commonly mentioned facilitator. Practice site, organization, and hospital system barriers included measures of emergency department throughput, the order in which test options are listed in electronic health records (EHR), lack of relevant decision support in EHRs, and payment incentives that maximize billing and encourage procedures rather than medical management or counseling patients on behavior change. Factors from different levels interacted to undermine evidence-based care. Most physicians received billing feedback, but quality metrics on evidence-based service use were nonexistent for the four decisions in this study.

Conclusions and Implications

Additional research and quality improvement may help to modify delivery systems to overcome barriers at multiple levels. Enhancing provider communication skills, improving decision support in EHRs, modifying workflows, and refining the design and interpretation of some quality metrics would help, particularly if combined with concurrent payment reform to realign financial incentives across stakeholders.