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Clinician Attitudes and Beliefs Associated with More Aggressive Diagnostic Testing

      Abstract

      Background

      Variation in clinicians’ diagnostic test utilization is incompletely explained by demographics and likely relates to cognitive characteristics. We explored clinician factors associated with diagnostic test utilization.

      Methods

      We used a self-administered survey of attitudes, cognitive characteristics, and reported likelihood of test ordering in common scenarios; frequency of lipid and liver testing in patients on statin therapy. Participants were 552 primary care physicians, nurse practitioners, and physician assistants from practices in 8 US states across 3 regions, from June 1, 2018 to November 26, 2019. We measured Testing Likelihood Score: the mean of 4 responses to testing frequency and self-reported testing frequency in patients on statins.

      Results

      Respondents were 52.4% residents, 36.6% attendings, and 11.0% nurse practitioners/physician assistants; most were white (53.6%) or Asian (25.5%). Median age was 32 years; 53.1% were female. Participants reported ordering tests for a median of 20% (stress tests) to 90% (mammograms) of patients; Testing Likelihood Scores varied widely (median 54%, interquartile range 43%-69%). Higher scores were associated with geography, training type, low numeracy, high malpractice fear, high medical maximizer score, high stress from uncertainty, high concern about bad outcomes, and low acknowledgment of medical uncertainty. More frequent testing of lipids and liver tests was associated with low numeracy, high medical maximizer score, high malpractice fear, and low acknowledgment of uncertainty.

      Conclusions

      Clinician variation in testing was common, with more aggressive testing consistently associated with low numeracy, being a medical maximizer, and low acknowledgment of uncertainty. Efforts to reduce undue variations in testing should consider clinician cognitive drivers.

      Keywords

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      References

        • Ganguli I
        • Lupo C
        • Mainor AJ
        • et al.
        Prevalence and cost of care cascades after low-value preoperative electrocardiogram for cataract surgery in fee-for-service Medicare beneficiaries.
        JAMA Intern Med. 2019; 179: 1211-1219
        • Korenstein D
        • Chimonas S
        • Barrow B
        • Keyhani S
        • Troy A
        • Lipitz-Snyderman A
        Development of a conceptual map of negative consequences for patients of overuse of medical tests and treatments.
        JAMA Intern Med. 2018; 178: 1401-1407
        • Schwartz AL
        • Landon BE
        • Elshaug AG
        • Chernew ME
        • McWilliams JM
        Measuring low-value care in Medicare.
        JAMA Intern Med. 2014; 174: 1067-1076
        • Segal JB
        • Nassery N
        • Chang HY
        • Chang E
        • Chan K
        • Bridges JF
        An index for measuring overuse of health care resources with Medicare claims.
        Med Care. 2015; 53: 230-236
        • Fisher ES
        • Wennberg DE
        • Stukel TA
        • Gottlieb DJ
        • Lucas FL
        • Pinder EL
        The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care.
        Ann Intern Med. 2003; 138: 288-298
        • Colla CH
        • Morden NE
        • Sequist TD
        • Schpero WL
        • Rosenthal MB
        Choosing Wisely: prevalence and correlates of low-value health care services in the United States.
        J Gen Intern Med. 2015; 30: 221-228
        • Radomski TR
        • Feldman R
        • Huang Y
        • et al.
        Evaluation of low-value diagnostic testing for 4 common conditions in the Veterans Health Administration.
        JAMA Netw Open. 2020; 3e2016445
        • Sirovich BE
        • Lipner RS
        • Johnston M
        • Holmboe ES
        The association between residency training and internists' ability to practice conservatively.
        JAMA Intern Med. 2014; 174: 1640-1648
        • Chen YA
        • Gray BG
        • Bandiera G
        • MacKinnon D
        • Deva DP
        Variation in the utilization and positivity rates of CT pulmonary angiography among emergency physicians at a tertiary academic emergency department.
        Emerg Radiol. 2015; 22: 221-229
        • O'Neill L
        • Kuder J
        Explaining variation in physician practice patterns and their propensities to recommend services.
        Med Care Res Rev. 2005; 62: 339-357
        • Shashar S
        • Ellen M
        • Codish S
        • Davidson E
        • Novack V
        Medical practice variation among primary care physicians: 1 decade, 14 health services, and 3,238,498 patient-years.
        Ann Fam Med. 2021; 19: 30-37
        • Schwartz AL
        • Jena AB
        • Zaslavsky AM
        • McWilliams JM
        Analysis of physician variation in provision of low-value services.
        JAMA Intern Med. 2019; 179: 16-25
        • Eguale T
        • Buckeridge DL
        • Winslade NE
        • Benedetti A
        • Hanley JA
        • Tamblyn R
        Drug, patient, and physician characteristics associated with off-label prescribing in primary care.
        Arch Intern Med. 2012; 172: 781-788
        • Little P
        • Dorward M
        • Warner G
        • Stephens K
        • Senior J
        • Moore M
        Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study.
        BMJ. 2004; 328: 444
        • Wu X
        • Jiang YN
        • Zhang YL
        • et al.
        Impact of physicians' personalities and behavioral traits on treatment-related decision-making for elderly acute myeloid leukemia.
        J Gen Intern Med. 2021; 36: 3023-3030
        • Barreto TW
        • Chung Y
        • Wingrove P
        • et al.
        Primary care physician characteristics associated with low value care spending.
        J Am Board Fam Med. 2019; 32: 218-225
        • Bouck Z
        • Ferguson J
        • Ivers NM
        • et al.
        Physician characteristics associated with ordering 4 low-value screening tests in primary care.
        JAMA Netw Open. 2018; 1e183506
        • Hong AS
        • Ross-Degnan D
        • Zhang F
        • Wharam JF
        Clinician-level predictors for ordering low-value imaging.
        JAMA Intern Med. 2017; 177: 1577-1585
        • Morgan DJ
        • Leppin AL
        • Smith CD
        • Korenstein D
        A practical framework for understanding and reducing medical overuse: conceptualizing overuse through the patient-clinician interaction.
        J Hosp Med. 2017; 12: 346-351
        • Abrams M
        • Nuzum R
        • Zezza M
        • Ryan J
        • Kiszla J
        • Guterman S
        The Affordable Care Act's payment and delivery system reforms: a progress report at five years.
        Issue Brief (Commonw Fund). 2015; 12: 1-16
        • Born K
        • Kool T
        • Levinson W
        Reducing overuse in healthcare: advancing Choosing Wisely.
        BMJ. 2019; 367: l6317
        • Colla CH
        • Mainor AJ
        • Hargreaves C
        • Sequist T
        • Morden N
        Interventions aimed at reducing use of low-value health services: a systematic review.
        Med Care Res Rev. 2017; 74: 507-550
        • Mafi JN
        • Reid RO
        • Baseman LH
        • et al.
        Trends in low-value health service use and spending in the US Medicare Fee-for-Service Program, 2014-2018.
        JAMA Netw Open. 2021; 4e2037328
        • Morgan DJ
        • Pineles L
        • Owczarzak J
        • et al.
        Accuracy of practitioner estimates of probability of diagnosis before and after testing.
        JAMA Intern Med. 2021; 181: 747-755
        • Casscells W
        • Schoenberger A
        • Graboys TB
        Interpretation by physicians of clinical laboratory results.
        N Engl J Med. 1978; 299: 999-1001
        • Fagerlin A
        • Sepucha KR
        • Couper MP
        • Levin CA
        • Singer E
        • BJ Zikmund-Fisher
        Patients' knowledge about 9 common health conditions: the DECISIONS survey.
        Med Decis Making. 2010; 30: 35s-52s
        • Gigerenzer G
        Reckoning with Risk: Learning to Live With Uncertainty.
        Penguin Books, London2003
        • Krouss M
        • Croft L
        • Morgan DJ
        Physician understanding and ability to communicate harms and benefits of common medical treatments.
        JAMA Intern Med. 2016; 176: 1565-1567
        • Manrai AK
        • Bhatia G
        • Strymish J
        • Kohane IS
        • Jain SH
        Medicine's uncomfortable relationship with math: calculating positive predictive value.
        JAMA Intern Med. 2014; 174: 991-993
        • Whiting PF
        • Davenport C
        • Jameson C
        • et al.
        How well do health professionals interpret diagnostic information? A systematic review.
        BMJ Open. 2015; 5e008155
        • Dolan ED
        • Mohr D
        • Lempa M
        • et al.
        Using a single item to measure burnout in primary care staff: a psychometric evaluation.
        J Gen Intern Med. 2015; 30: 582-587
        • Allison JJ
        • Kiefe CI
        • Cook EF
        • Gerrity MS
        • Orav EJ
        • Centor R
        The association of physician attitudes about uncertainty and risk taking with resource use in a Medicare HMO.
        Med Decis Making. 1998; 18: 320-329
        • Katz DA
        • Williams GC
        • Brown RL
        • et al.
        Emergency physicians' fear of malpractice in evaluating patients with possible acute cardiac ischemia.
        Ann Emerg Med. 2005; 46: 525-533
        • Scherer LD
        • Caverly TJ
        • Burke J
        • et al.
        Development of the Medical Maximizer-Minimizer Scale.
        Health Psychol. 2016; 35: 1276-1287
        • Pearson SD
        • Goldman L
        • Orav EJ
        • et al.
        Triage decisions for emergency department patients with chest pain: do physicians' risk attitudes make the difference?.
        J Gen Intern Med. 1995; 10: 557-564
        • Schwartz LM
        • Woloshin S
        • Black WC
        • Welch HG
        The role of numeracy in understanding the benefit of screening mammography.
        Ann Intern Med. 1997; 127: 966-972
        • Kanzaria HK
        • Hoffman JR
        • Probst MA
        • Caloyeras JP
        • Berry SH
        • Brook RH
        Emergency physician perceptions of medically unnecessary advanced diagnostic imaging.
        Acad Emerg Med. 2015; 22: 390-398
        • Lyu H
        • Xu T
        • Brotman D
        • et al.
        Overtreatment in the United States.
        PLoS One. 2017; 12e0181970
        • Studdert DM
        • Mello MM
        • Sage WM
        • et al.
        Defensive medicine among high-risk specialist physicians in a volatile malpractice environment.
        JAMA. 2005; 293: 2609-2617
        • Garcia-Retamero R
        • Cokely ET
        • Wicki B
        • Joeris A
        Improving risk literacy in surgeons.
        Patient Educ Couns. 2016; 99: 1156-1161
        • Johnson TV
        • Abbasi A
        • Schoenberg ED
        • et al.
        Numeracy among trainees: are we preparing physicians for evidence-based medicine?.
        J Surg Educ. 2014; 71: 211-215
        • Sheridan SL
        • Pignone M
        Numeracy and the medical student's ability to interpret data.
        Eff Clin Pract. 2002; 5: 35-40
        • Petrova D
        • Kostopoulou O
        • Delaney BC
        • Cokely ET
        • Garcia-Retamero R
        Strengths and gaps in physicians' risk communication: a scenario study of the influence of numeracy on cancer screening communication.
        Med Decis Making. 2018; 38: 355-365
        • Evron JM
        • Reyes-Gastelum D
        • Banerjee M
        • et al.
        Role of patient maximizing-minimizing preferences in thyroid cancer surveillance.
        J Clin Oncol. 2019; 37: 3042-3049
        • Scherer LD
        • Shaffer VA
        • Caverly T
        • DeWitt J
        • BJ Zikmund-Fisher
        Medical maximizing-minimizing predicts patient preferences for high- and low-benefit care.
        Med Decis Making. 2020; 40: 72-80
        • Scherer LD
        • Kullgren JT
        • Caverly T
        • et al.
        Medical maximizing-minimizing preferences predict responses to information about prostate-specific antigen screening.
        Med Decis Making. 2018; 38: 708-718
        • Franks P
        • Williams GC
        • Zwanziger J
        • Mooney C
        • Sorbero M
        Why do physicians vary so widely in their referral rates?.
        J Gen Intern Med. 2000; 15: 163-168
        • Ganguli I
        • Simpkin AL
        • Colla CH
        • et al.
        Why do physicians pursue cascades of care after incidental findings? A national survey.
        J Gen Intern Med. 2020; 35: 1352-1354
        • Schneider A
        • Löwe B
        • Barie S
        • Joos S
        • Engeser P
        • Szecsenyi J
        How do primary care doctors deal with uncertainty in making diagnostic decisions? The development of the 'Dealing with Uncertainty Questionnaire' (DUQ).
        J Eval Clin Pract. 2010; 16: 431-437
        • Alam R
        • Cheraghi-Sohi S
        • Panagioti M
        • Esmail A
        • Campbell S
        • Panagopoulou E
        Managing diagnostic uncertainty in primary care: a systematic critical review.
        BMC Fam Pract. 2017; 18: 79
        • Begin AS
        • Hidrue M
        • Lehrhoff S
        • Del Carmen MG
        • Armstrong K
        • Wasfy JH
        Factors associated with physician tolerance of uncertainty: an observational study.
        J Gen Intern Med. 2021; : 1-7
        • Pines JM
        • Hollander JE
        • Isserman JA
        • et al.
        The association between physician risk tolerance and imaging use in abdominal pain.
        Am J Emerg Med. 2009; 27: 552-557
        • Pines JM
        • Isserman JA
        • Szyld D
        • Dean AJ
        • McCusker CM
        • Hollander JE
        The effect of physician risk tolerance and the presence of an observation unit on decision making for ED patients with chest pain.
        Am J Emerg Med. 2010; 28: 771-779
        • Adesoye T
        • Kimsey LG
        • Lipsitz SR
        • et al.
        Geographic variation in Medicare and the military healthcare system.
        Am J Manag Care. 2017; 23: e259-e264
        • Chen C
        • Petterson S
        • Phillips R
        • Bazemore A
        • Mullan F
        Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries.
        JAMA. 2014; 312: 2385-2393
        • Mafi JN
        • Landon BE
        Comparing use of low-value health care services among U.S. advanced practice clinicians and physicians.
        Ann Intern Med. 2017; 166: 77
        • Auerbach DI
        • Staiger DO
        • Buerhaus PI
        Growing ranks of advanced practice clinicians - implications for the physician workforce.
        N Engl J Med. 2018; 378: 2358-2360
        • Bertakis KD
        • Helms LJ
        • Azari R
        • Callahan EJ
        • Robbins JA
        • Miller J
        Differences between family physicians' and general internists' medical charges.
        Med Care. 1999; 37: 78-82