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BMC Health Services Research

, 14:176

Quality, performance, safety and outcomes

Abstract

BackgroundPhysicians often select clinical management strategies not strongly supported by evidence or guidelines. Our objective was to examine the likelihood of selecting, and rationale for pursuing, clinical management strategies with more or less guideline support among physicians using clinical vignettes of eight common medical admissions.

MethodsWe conducted a cross-sectional survey using clinical vignettes of attending physicians and housestaff at one internal medicine program in New York City. Each clinical vignette included a brief clinical scenario and a varying number of clinical management strategies: diagnostic tests, consultations, and treatments, some of which had strong evidence or guideline support Level 1 strategies while others had limited evidence or guideline support Level 3 strategies. Likelihood of selecting a given management strategy was assessed using Likert scales and multiple response options were used to indicate rationales for selections.

ResultsOur sample included 79 physicians; 68 86% were younger than 40 years of age, 34 43% were female. There were 31 attending physicians 39% and 48 housestaff 61% and 39 49% had or planned to have primarily primary care internal medicine clinical responsibilities. Overall, physicians were more likely to select Level 1 strategies -always- or -most of the time- when compared with Level 3 strategies 82% vs. 43%; p < 0.001, with wide variation across the eight medical admissions. There were no differences between attending and housestaff physician likelihood of selecting Level 3 strategies 47% vs. 45%, p = 0.36. Supportive evidence and local practice patterns were the two most common rationales behind selections; supportive evidence was cited as the most common rationale for selecting Level 1 when compared with Level 3 strategies 63% versus 30%; p < 0.001, whereas ruling out other severe conditions was cited most often for Level 3 strategies.

ConclusionsFor eight common medical admissions, physicians selected more than 80% of management strategies with strong evidence or guideline support, but also selected more than 40% of strategies for which there was limited evidence or guideline support. The promotion of evidence-based care, including the avoidance of care that is not strongly supported by evidence or guidelines, may require better evidence dissemination and educational outreach to physicians.

Electronic supplementary materialThe online version of this article doi:10.1186-1472-6963-14-176 contains supplementary material, which is available to authorized users.

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Author: Kristofer L Smith - Sarah Ashburn - Jenerius A Aminawung - Micah Mann - Joseph S Ross

Source: https://link.springer.com/



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