Table 1. Factors that contribute to each domain of the framework for overuse of care.

Domain	Factors	Evidence	Specific impact	Likely magnitude of effect on overuse
Culture of health care consumption	Consumerism and advocating for one's own health Information found on the internet and through the media General expectations about the appropriate amount and type of care Belief that you get what you pay for	Strength: weak None related to specific factors Evidence related to: Variations in care27, 55 General enthusiasm for screening56	Likely leads to more general utilization, overuse, and use of costlier alternatives	Moderate
Patient factors and experiences	Prior health care experiences (patient and family) Demographic factors and education Health literacy and numeracy Patient interactions with health center staff Patient interactions with other clinicians	Strength: weak to strong Evidence related to: Impact of race/ethnicity on overuse and underuse57, 58 Patient expectations59, 60 Patient desire for investigation and answers61	Variable; can contribute to overuse or protect against overuse	Moderate. Interventions related to with patient demographics not defined
Culture of professional medicine	Influence of broad regulations and metrics Value placed on finding answers, certainty Value placed on doing things Discomfort with discussing/admitting diagnostic uncertainty to others (strong vs. weak) Fear of missing diagnoses New high tech solutions more valued and reimbursed.	Strength: absent to moderate No evidence exploring role of most individual factors Evidence related to: Association between local culture and overuse62-64(moderate evidence) Physician factors and geographic variations65	Overuse performance measures can limit overuse but measures for preventing underuse may lead to overuse Emphasis on certainty, technology and active intervention likely contribute to overuse	Moderate to high
Clinician attitudes and beliefs	Personality and personal biases Poor numeracy and knowledge of evidence Past experiences with other patients with the same condition Knowledge of and attitudes toward particular patient Fear of litigation (defensive medicine) Clinician-clinician interactions Clinician-staff interactions Comfort with discussing cost or other issues Discomfort with diagnostic uncertainty	Strength: weak Evidence related to: Physician beliefs and geographic variations28 Variation in utilization based on specific physician characteristics66-68 Self-reported drivers of physician overuse26	Traditionally mostly push toward more care Poor numeracy, lack of knowledge, discomfort with uncertainty, sampling biases from past experiences, interactions with other clinicians, fear of litigation, and some personality traits likely lead to overuse Patient continuity helps prevent overuse	High
Practice environment	Financial incentives Practice norms within the group and expectations from the affiliated health system Structures which influence specific practices Risk of lawsuits Performance metrics may encourage overuse	Strength: weak Practice norms not well studied Evidence related to: Local cultural norms and aggressive care69-71 Residency training and utilization29, 72, 73 Financial incentives41, 74 (weak evidence) General influence of practice setting75 Quality metrics may encourage too much care and overuse76, 77	Local cultural norms are influential (including local training culture) Other factors vary based on specifics	High
The patient-clinician interaction	Specific communication styles Concordance of culture, race, language, and gender Prior experiences with each other Visit priorities	Strength: moderate for shared decision making, continuity, weak for other factors Evidence related to: Continuity of care and overuse21 Continuity of care and utilization22,23 Communication24 Shared decision making and overuse25	Continuity of care likely reduces overuse Shared decision making likely reduces overuse Unclear impact of culture and language	High

Note: Likely magnitude of effect on overuse was determined by author consensus based on strength and breadth of evidence and other factors