Jennifer Arney

Choosing Wisely and the Perceived Drivers of Endoscopy Use

Choosing Wisely is a campaign led by the American Board of Internal Medicine (ABIM) Foundation in collaboration with specialty medical societies including the American Gastroenterological Association (AGA)1. Choosing Wisely seeks to reduce several categories of overutilization of health care services (e.g., overtreatment, and failures in care coordination and execution of care processes)2. Choosing Wisely is based on principles of Parsimonious Medicine: an appeal to professionalism and physicians’ “good, sound judgment” to identify and apply clinical evidence 3. Parsimonious medicine suggests that appropriate utilization occurs when physician judgment and best evidence are applied within the context of individual patient’s needs3. Choosing Wisely addresses both physicians and patients through the publication of lists of “Five Things Physicians and Patients Should Question” for each specialty. The Choosing Wisely items identified by the AGA highlight potential overutilization of 1) pharmacologic treatments for gastroesophageal reflux disease, 2) screening colonoscopy in average risk individuals, 3) surveillance colonoscopy in individuals with low-risk polyps, 4) surveillance esophagogastroduodenoscopy (EGD) in individuals with Barrett’s Esophagus (BE), and 5) computed tomography (CT) in individuals with functional abdominal pain.1 The success of Choosing Wisely will depend on how patients and physicians weight the importance of best evidence against other factors that shape decisions at the clinical encounter. As part of a patient-centered, comparative effectiveness study of screening and surveillance esophagogastroduodenoscopy (EGD), we conducted qualitative interviews to explore patient and physician perceptions of one of the AGA Choosing Wisely items.4 Analysis of these interviews identified factors perceived to influence under and over utilization of surveillance EGD for Barrett’s Esophagus in the context of AGA clinical practice guidelines. We conducted in-depth qualitative interviews with 20 patients with BE who use the Veterans Administration (VA) system and 14 gastroenterologists from three practice settings: tax-supported public, private academic, and VA settings. We concluded sampling for each subgroup at the point of thematic saturation5. Interview content was informed by models of decision-making6. Interviews with patients elicited information about their experiences, perceptions, and attitudes regarding BE and surveillance EGD. Interviews with physicians elicited perceptions of practice guidelines and decision making regarding surveillance EGD in patients with BE. All interviews were recorded, transcribed, and analyzed for content.5 Of our sample of 20 patients with BE, the mean age of participants was 62.9±7.3 years; all male; and 10 had BE without dysplasia and 9 had BE with low-grade dysplasia. All of the 14 gastroenterologists interviewed were experienced endoscopists, 36% were female, 50% practiced in private settings full or part time; and had a median of 14 (range 1–36) years post-fellowship experience. Table 1 describes quotes from patients and gastroenterologists that frame the drivers of utilization of EGD for patients with BE as part of guideline-based cancer surveillance. Figure 1 depicts these 9 themes as drivers of utilization for surveillance EGD. Figure 1 Table 1 Drivers of Utilization Among Patients and Gastroenterologists Our interviews identified drivers of over and under utilization of EGD within the context of BE surveillance. Patients and physicians endorsed many factors (Figure 1) that drive utilization of EGD, other than the quality of evidence, that may not be influenced by appeals for professionalism or quality of evidence. These factors include, access and payments for healthcare (for patients), financial incentives and medical-legal considerations (for physicians). The results of our study specifically explore one of the Choosing Wisely items co-sponsored by AGA: follow-up surveillance examination should not be performed in less than three years as per published guidelines for BE patients without dysplasia1. However, current practice is not indicative of adherence to this item; for example, a recent three-site study (including one VA facility) found EGD overutilization was common among BE patients and insurance-related incentives were the primary driver of utilization6. The emphasis that Choosing Wisely places on Parsimonious Medicine is unlikely to mitigate the many drivers of overtreatment given some of the current evidence and structural issues related to heathcare delivery in a largely fee-for-service system. High quality evidence is critical because it anchors definitions of appropriate utilization (as illustrated in Figure 1). However, three of the five Choosing Wisely items from the AGA directly address overutilization of endoscopy (colonoscopy and EGD) where evidence guiding the optimal time interval between repeat studies is modest at best, yet there are multiple perceived factors driving overutilization. Moreover, systematic changes affecting incentive structures and medico-legal concerns are needed to encourage and enable the types of shared decisions that are consistent with best evidence. Without incentives to counteract the factors favoring overutilization, Choosing Wisely will struggle to meaningfully impact clinical decision making.

Patient-centered, comparative effectiveness of esophageal cancer screening: protocol for a comparative effectiveness research study to inform guidelines for evidence-based approach to screening and surveillance endoscopy

BackgroundThe comparative effectiveness (CE) of endoscopic screening (versus no screening) for Barrett’s esophagus (BE) in patients with GERD symptoms, or among different endoscopic surveillance strategies in patients with BE, for the early detection of esophageal adenocarcinoma (EA) is unknown. Furthermore, it is unclear if patients or providers have or will adopt any of these strategies (screening only, screening and surveillance, vs. none), irrespective of their effectiveness. Endoscopic screening and surveillance is expensive and can be risky. Therefore, it is imperative to establish the CE and acceptability about the risks and outcomes related to these practices to better inform expert recommendations and provider-patient decisions.Methods/ResultsWe propose a mixed methods study which will involve: (1) an analysis of secondary databases (VA and VA-Medicare linked datasets for 2004–09) to examine CE of endoscopic screening and surveillance in an observational study cohort (an estimated 680,000 patients with GERD; 25,000–30,000 with BE; and 3,000 with EA); (2) a structured electronic medical record (EMR) review on a national sample of patients using VA EMRs to verify all EA cases, identify cancer stage, cancer-targeted therapy, and validate the screening and surveillance endoscopy; and (3) qualitative in depth interviews with patients and providers to elicit preferences, norms, and behaviors to explain clinical contexts of these findings and address gaps arising from the CE study.ConclusionThis study will compare clinical strategies for detecting and monitoring BE, a pre-cancerous lesion. Additionally, by eliciting acceptability of these strategies for patients and providers, we will be able to propose effective and feasible strategies that are likely to be implemented in routine use. Findings will inform recommendations for clinical practice guidelines. Our innovative approach is consistent with the methodological standards of patient-centered outcomes research, and our findings will offer a significant contribution to the literature on cancer surveillance.Trial RegistrationNot applicable

Factors Shaping Physicians’ Willingness to Accommodate Medication Requests:

Medical decisions, including physicians’ prescribing behaviors, are shaped by a complex interplay of clinical and nonclinical factors. We aim to determine how physician, patient, and relationship characteristics influence physicians’ decisions to accommodate brand-name prescription drug requests. We applied multivariate logistic regression to data from the Attitudinal and Behavioral Effects of Direct-to-Consumer Promotion of Prescription Drugs physician survey. We used a national probability sample of 500 primary care and specialty physicians reporting on a clinical encounter that involved a prescription drug request. Independent variables include physician’s assessment of the patient’s understanding of risks and benefits of a requested medication, whether the patient had the condition the drug treats, duration of the clinical relationship, and physician’s age, area of practice, years of experience, and gender. These variables were used to predict whether the physician prescribed the requested drug. Physicians were more willing to accommodate requests when they believed that patients had a clear understanding of the drug’s risks and when patients had the condition the drug treats. Primary care practitioners, compared to specialists, had higher odds of prescribing a requested drug. We conclude that clinical and communicative factors shape physicians’ decisions to prescribe requested brand-name drugs. Findings offer insight into the influence that direct-to-consumer advertising can have in medical encounters, and may guide efforts to enhance physician–patient communication and shared decision making.

Qualitative findings on building a partnered approach to implementation of a group-based diabetes intervention in VA primary care

Objective Conduct a formative evaluation to inform the implementation of ‘Empowering Patients in Chronic Care’ (EPIC), an evidence-based interdisciplinary group medical appointment intervention to improve collaborative goal-setting in patients with treated but uncontrolled diabetes. Design The formative evaluation involved qualitative, in-depth interviews with clinicians, structured according to the Promoting Action on Research in Health Services framework. Interviews elicited (1) participants’ knowledge regarding interdisciplinary group self-management and goal-setting programmes and how well clinicians embrace these interventions (evidence), (2) physical and social climate at each target facility and how the intervention can best be embedded into routine primary care (context) and (3) site-specific needs to be addressed by our implementation team and clinicians’ preparedness and intentions to participate in the intervention (facilitation). Setting Clinicians were part of a primary care setting at one of five participating medical facilities within one Veterans Health Administration Veterans Affairs regional network. Participants We interviewed a snowball sample of 35 interdisciplinary clinicians engaged in diabetes management, practising leadership and administrators at target sites. Results Most participants had previous experience with diabetes group self-management programmes and viewed group appointments as an effective approach to enhancing care. Discussions about existing group appointments provided a context for evaluating potential barriers and facilitators to implementing EPIC into target sites. Interviews revealed clinicians’ expectations about the roles they would play in the intervention, their assessments of the roles and strategies to facilitate their performance in those roles. Conclusions Successful implementation of evidence-based practices into routine care requires a partnered approach with engaged local staff. The intervention should address local goals and research objectives to encourage bidirectional engagement. Robust partnerships are nurtured further by sustained, open communication and must consider the context, target population and local experience to address barriers and facilitators to implementation.