Facilitating Evidence-Based Clinical Decision Making

Prepared for
The Robert Wood Johnson Foundation

A substantial portion of U.S. health care spending is for services of unclear effectiveness, whereas many highly effective services are underused. Furthermore, patterns of care across communities, specialties, and practices vary widely, even when physician leaders and professional societies embrace evidence‑based practices. One important challenge is that at the point of care, practicing physicians face a variety of barriers to delivering the most evidence-based solutions to address patients’ concerns. Patients’ preferences play a key role in determining the care they receive, and various factors can influence their likelihood of seeking, accepting, and acting upon the evidence-based recommendations physicians provide to them. Thus, it is important to consider the needs of both patients and physicians in efforts to reduce inappropriate care and enhance the use of evidence-based services.

With this in mind, we undertook a project, supported by the Robert Wood Johnson Foundation, to understand the barriers and facilitators at the point of care that influence patients’ and physicians’ decisions, and to highlight how payers, purchasers, and medical practices can better support physicians and patients in their quest for more effective and evidence-based care. In this effort, we focused on four representative clinical cases, drawing from recommendations in the Choosing Wisely® program. These cases reflect different types of decisions often faced by physicians and patients, with clear evidence on how to proceed.

Our first case concerns the choice of which diagnostic test (if any) to order for a child presenting with suspected appendicitis. Our second case involves the use of cardiac imaging technology as a regular part of long-term monitoring in stable patients with known coronary heart disease. Our third case involves weighing medical and surgical therapy for patients with intermittent leg pain from peripheral vascular disease. The final case concerns a decision made after an initial treatment has already been selected and deemed successful: discussion about reducing medication dose to the lowest effective level in patients with gastroesophageal reflux disease (GERD).

To explore barriers to and facilitators of evidence-based decisions for these four clinical cases at the point of care, we conducted literature reviews, semistructured interviews with specialty physicians, focus groups with health care consumers, and discussions with key stakeholders. The literature reviews systematically identified factors influencing physicians’ and patients’ decision making at the point of care. These reviews then informed the protocols for a series of interviews with medical and surgical specialists, and focus groups with health care consumers, designed to further explore barriers to and facilitators of evidence-based medical care.

Ultimately, we engaged 36 specialists and 70 health care consumers as part of these activities. Upon completion of the interviews and focus groups, we organized a day-long stakeholder meeting to present our findings to 50 carefully selected clinician leaders, commercial and government payers, health care purchasers, clinic practice organization and payment experts, and consumer representatives and advocates. We invited these stakeholders to react to the interview and focus group findings, and to discuss the options available to policymakers, payers, purchasers, and delivery organizations to facilitate physicians’ recommendations of evidence‑based care, as well as patients’ receptiveness to these recommendations.

Under "Related Publications" to the right, you can access the two reports produced under this project, which offer more detail on the opportunities for payers, delivery systems,  health insurers, and other purchasers to support evidence-based decision making by providers and patients in typical point of care situations.