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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 payment incentives that maximize billing and encourage procedures rather than medical management or counseling patients on behavior change. Factors from different levels interacted to undermine evidence-based care. Most physicians received billing feedback, but quality metrics on evidence-based service use were nonexistent for the four decisions in this study. Conclusions and Implications: Additional research and quality improvement may help to modify delivery systems to overcome barriers at multiple levels. Enhancing provider communication skills, improving decision support in EHRs, modifying workflows, and refining the design and interpretation of some quality metrics would help, particularly if combined with concurrent payment reform to realign financial incentives across stakeholders.

Despite advances in transition service delivery and increased knowledge of research-supported transition strategies, longstanding service and systems issues continue to impede optimal transition outcomes for students and youth with disabilities. These issues are evidenced in challenges that students with disabilities continue to face as they prepare for and experience the transition from school to employment and adult life. Compared with their peers without disabilities, students with disabilities can still expect lower school completion rates (Stark & Noel, 2015), lower adult employment participation (Bureau of Labor Statistics, 2016), higher dependence on public income support (Davies, Rupp, & Wittenburg, 2009), and higher incidence of poverty (DeNavas-Walt & Proctor, 2014). In addition, there remains an ongoing challenge to link students to adult support services that many youth with disabilities need to achieve and sustain postschool employment success (Certo et al., 2009; Clark & Unruh, 2009). The need persists to identify cohesive transition service delivery models that incorporate the multiple factors, supported by a growing body of research, that contribute to successful transition from school to adult employment for these youth. Given these circumstances, researchers, transition policy makers, and transition service practitioners have identified strategies to mitigate barriers to successful transition to employment for students and youth with disabilities. Since the publication of a compilation of research-supported transition components, called the Guideposts for Success (National Collaborative on Workforce and Disability for Youth [NCWD/Y], 2005), more research has emerged to support several specific factors that contribute to a higher likelihood of postschool employment success. First, several studies continue to reinforce the importance of work experience in secondary school, especially paid employment, in influencing adult employment (e.g., Carter, Austin, & Trainor, 2011; Wehman et al., 2014; Test et al., 2009). Second, family involvement and expectations can influence later employment success of students and youth with 713167R CBXXX10.1177/0034355217713167Rehabilitation Counseling BulletinLuecking et al.

In July 2010, the Department of Veterans Affairs (VA) simplified the process of obtaining veterans' disability compensation (DC) for veterans with posttraumatic stress disorder (PTSD) who served in combat zones but not in combat roles. In this article, we use data from the Current Population Survey (CPS) Veterans Supplement to estimate the impacts of the change in the VA PTSD rule on DC benefit receipt and self-reported cognitive disability. We hypothesize that the easing of eligibility rules led to an increase in DC receipt among veterans who served in combat zones but not in combat roles. It may also have led to reduced stigma among veterans with regard to reporting cognitive disability. Our results are consistent with these hypotheses. Self-reported rates of VA disability and DC receipt increased significantly among combat zone veterans. Self-reported VA disability rating and experience of cognitive disability also increased, but these increases were not statistically significant. During the same period, the rate of self-reported disability other than cognitive disability remained the same.

We conduct a narrative literature review using four real-world cases of clinical decisions to show how barriers to the use of evidence-based medicine affect physician decision-making at the point of care, and where adjustments could be made in the healthcare system to address these barriers. Our four cases constitute decisions typical of the types physicians make on a regular basis: diagnostic testing, initial treatment and treatment monitoring. To shed light on opportunities to improve patient care while reducing costs, we focus on barriers that could be addressed through changes to policy and/or practice at a particular level of the healthcare system. We conclude by relating our findings to the passage of the Medicare Access and Children's Health Insurance Program Reauthorization Act in April 2015.