Barriers to and Facilitators of Evidence-Based Decision Making at thePoint of Care

摘要

>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 paymentincentives that maximize billing and encourage procedures rather than medicalmanagement or counseling patients on behavior change. Factors from differentlevels interacted to undermine evidence-based care. Most physicians receivedbilling feedback, but quality metrics on evidence-based service use werenonexistent for the four decisions in this study. >Conclusions andImplications: Additional research and quality improvement may help tomodify delivery systems to overcome barriers at multiple levels. Enhancingprovider communication skills, improving decision support in EHRs, modifyingworkflows, and refining the design and interpretation of some quality metricswould help, particularly if combined with concurrent payment reform to realignfinancial incentives across stakeholders.