Doctors who follow guidelines for basic procedures generally achieve better outcomes than those who deviate
Harvard Gazette
By Jake Miller
HMS Communications
February 10, 2022
iStock by Getty Images
Executive Summary
by Joaquim Cardoso MSc.
Chief Editor of The Health Strategy Institute blog
February 21, 2022
What is the problem?
- Some estimates suggest that approximately 25 percent of health care spending in the U.S. is wasteful.
- “Researchers have long suspected that much of that waste lies in the variation of the appropriateness of care from one physician to another,” Song said. “This study offers evidence that this problem is large and widespread across specialties.”
- Reducing this waste will require addressing multiple sources of unnecessary spending, one of which is inappropriate clinical decision-making
How was the study conducted?
- The researchers examined medical insurance records from 2016 to 2019, involving care provided in 14 common clinical scenarios by 8,788 physicians, from seven different specialties, across five municipal areas across the United States.
- In the study, researchers looked at whether physicians applied evidence-based guidelines to choices they made in common clinical scenarios.
- To minimize the chance that variation in the care received may be due to patient differences rather than physician decision-making, the researchers compared similar patients with similar clinical and demographic characteristics.
What were the findings?
- The study found significant variations in care between physicians
- Some physicians are far more likely to deliver appropriate care than others in the same geographic area or health care system,
- In some of the cases, physicians who made the most clinically appropriate decisions were five to 10 times more likely to use the recommended standard of care
- Doctors who follow guidelines for basic procedures generally achieve better outcomes than those who deviate
What is a good example?
One clear example is arthroscopic knee surgery for new osteoarthritis” “Several randomized clinical trials have shown that the surgery is no better than no surgery or placebo treatments.” In the arthroscopic surgery for new osteoarthritis scenario:
- The top 20 percent of surgeons in the study performed the surgery on only 2 to 3 percent of their patients.
- By contrast, between 26 and 31 percent of patients with the same condition in the same cities got surgery if they saw a surgeon from the bottom 20 percent.
What are the other findings?
Within MSAs (Metropolitan Statistical Areas), physician-level variations were qualitatively similar across measures. For example:
- Statin therapy in patients with coronary artery disease ranged from 54.3% to 70.9% in the first quintile of cardiologists
to 30.5% to 42.6% in the fifth quintile.
- Upper endoscopy in patients with gastroesophageal reflux disease without alarm symptoms spanned 14.6% to 16.9% in the first quintile of gastroenterologists
to 28.2% to 33.8% in the fifth quintile.
- Among patients with new knee or hip osteoarthritis,
2.1% to 3.4% received arthroscopy in the first quintile of orthopedic surgeons,
whereas 25.5% to 30.7% did in the fifth quintile.
- Appropriate prenatal screening among pregnant patients ranged from 82.6% to 93.6% in the first quintile of obstetricians
to 30.9% to 65.7% in the fifth quintile.
What are the implications?
- Further research into how and why doctors differ in the decisions they make can help medical schools, teaching hospitals, and continuing education programs fine-tune their training and improve value of care.
- This type of evidence, if replicated in a rigorous way, may also empower patients, employers, and payers to choose physicians who provide higher value care in their region, allowing consumers voting with their feet to stimulate practice improvement and competition on quality
- In the future, “it would make more sense to develop more clinically nuanced incentives to encourage patients to choose physicians who provide higher value care that ensures better patient outcomes aligned with evidence-based approaches (Song) “
Find below, the long read of the Harvard Gazette article, followed by an excerpt of the original publication
LONG READ
Study finds significant variations in care between physicians
Doctors who follow guidelines for basic procedures generally achieve better outcomes than those who deviate
Harvard Gazette
By Jake Miller
HMS Communications
February 10, 2022
iStock by Getty Images
Some physicians are far more likely to deliver appropriate care than others in the same geographic area or health care system, according to a new study led by Zirui Song of the Department of Health Care Policy in the Blavatnik Institute at Harvard Medical School, in collaboration with colleagues at Massachusetts General Hospital, Brigham and Women’s Hospital, Embold Health, University of Michigan, and Vanderbilt University.
Some physicians are far more likely to deliver appropriate care than others in the same geographic area or health care system,
In the study, researchers looked at whether physicians applied evidence-based guidelines to choices they made in common clinical scenarios.
The analysis, published Jan. 28 in JAMA Health Forum, found significant, sometimes substantial, differences in how often individual physicians chose the recommended specific treatments or course of action.
“We looked at a set of situations where clear-cut guidelines have been in place for years, with the hope of limiting variation in physician decision-making and promoting the use of the most appropriate care, based on rigorous evidence,” said study lead author Song, HMS associate professor of health care policy and a general internist at MGH.
The analysis, … found significant, sometimes substantial, differences in how often individual physicians chose the recommended specific treatments or course of action.
“In some of the cases we looked at, physicians who made the most clinically appropriate decisions were five to 10 times more likely to use the recommended standard of care than peers in the same specialties and cities whose decisions tended to be the least appropriate. The differences we found are a cause for concern,” Song said.
“In some of the cases we looked at, physicians who made the most clinically appropriate decisions were five to 10 times more likely to use the recommended standard of care
Many clinical situations are complex, requiring physicians to make clinical decisions without the help of guidelines with a strong evidence base and choose from options that involve substantial uncertainty for patient outcomes.
These are not the type of scenarios the researchers analyzed. Instead, they looked at more straightforward, simpler situations with a clear clinical decision and guideline-recommended pathway of care.
Based on evidence from randomized clinical trials and long-term observational studies, there are many clinical scenarios where a physician can provide effective care that maximizes clinical benefit and minimizes risk to the patient by adhering to well-known clinical guidelines, Song said.
Even if a given patient’s unique circumstances might make the physician deviate from those guidelines, on average across many patients, those guidelines would generally point to higher value care.
For example, most pregnant patients should receive a common set of prenatal screenings, and patients with nonemergency hip or knee problems should receive some physical therapy before the decision is made to undergo surgery.
The researchers examined medical insurance records
- from 2016 to 2019,
- involving care provided in 14 common clinical scenarios by 8,788 physicians
- from seven different specialties
- across five municipal areas across the United States.
To minimize the chance that variation in the care received may be due to patient differences rather than physician decision-making, the researchers compared similar patients with similar clinical and demographic characteristics.
“One clear example is arthroscopic knee surgery for new osteoarthritis,” Song said. “Several randomized clinical trials have shown that the surgery is no better than no surgery or placebo treatments.”
With such clear-cut evidence, Song said he was surprised and concerned to see a marked variation in arthroscopic knee surgery rates on similar patients with new osteoarthritis among surgeons in the same cities.
For the study, the researchers divided physicians into five quintiles based on how likely they were to follow the guidelines and provide the recommended care.
- In the arthroscopic surgery for new osteoarthritis scenario, the top 20 percent of surgeons in the study performed the surgery on only 2 to 3 percent of their patients.
- By contrast, between 26 and 31 percent of patients with the same condition in the same cities got surgery if they saw a surgeon from the bottom 20 percent.
“One clear example is arthroscopic knee surgery for new osteoarthritis,” … “Several randomized clinical trials have shown that the surgery is no better than no surgery or placebo treatments.”
.. the top 20 percent of surgeons in the study performed the surgery on only 2 to 3 percent of their patients…
the bottom 20 percent of surgeons performed the surgery to 26 and 31 percent of patients — with the same condition in the same cities
Geographic variations
The first observations of widespread differences in clinical decision-making were published two decades ago, including research by the Dartmouth Atlas of Health Care, but focused on geographic variation between different regions of the country.
A 2013 National Academies of Medicine committee led by Alan Garber, provost of Harvard University, and Joseph Newhouse, HMS professor of health care policy, called for a greater emphasis on understanding differences in individual physician decision-making, rather than geography, for improving quality of care.
“In the last decade, however, rigorous measurement of within-area, between-physician variations in decision-making remains sparse,” Song said. “This study aims to help fill that gap.”
Song noted that the variations in the study were most likely related to differences in individual physicians, not differences in practices or health systems, as the variation between individual doctors working in the same organization was greater than the differences in performance between organizations.
The variations in the study were most likely related to differences in individual physicians, not differences in practices or health systems
Further research into how and why doctors differ in the decisions they make can help medical schools, teaching hospitals, and continuing education programs fine-tune their training and improve value of care.
This type of evidence, if replicated in a rigorous way, may also empower patients, employers, and payers to choose physicians who provide higher value care in their region, allowing consumers voting with their feet to stimulate practice improvement and competition on quality, Song said.
For example, right now some employers and insurers require higher co-pays for patients who go to higher-priced hospitals to encourage use of lower-priced hospitals. Generally, appropriateness of clinical decisions is not factored in.
In the future, Song said, it would make more sense to develop more clinically nuanced incentives to encourage patients to choose physicians who provide higher value care that ensures better patient outcomes aligned with evidence-based approaches.
Some estimates suggest that approximately 25 percent of health care spending in the U.S. is wasteful.
Reducing this waste will require addressing multiple sources of unnecessary spending, one of which is inappropriate clinical decision-making, researchers noted.
Reducing this waste will require addressing multiple sources of unnecessary spending, one of which is inappropriate clinical decision-making, researchers noted.
“Researchers have long suspected that much of that waste lies in the variation of the appropriateness of care from one physician to another,” Song said. “This study offers evidence that this problem is large and widespread across specialties.”
This research was supported by grants from the National Institutes of Health, Arnold Ventures, the National Institute of Diabetes and Digestive and Kidney Disease, and Harvard Catalyst.
Originally published at https://news.harvard.edu on February 10, 2022.
ORIGINAL PUBLICATION
Physician Practice Pattern Variations in Common Clinical Scenarios Within 5 US Metropolitan Areas
JAMA Network
Zirui Song, MD, PhD1,2; Sneha Kannan, MD2; Robert J. Gambrel, MS, MA3; Molly Marino, PhD, MPH3; Muthiah Vaduganathan, MD, MPH4; Mark A. Clapp, MD, MPH5; Jacqueline A. Seiglie, MD2,6; Patricia P. Bloom, MD7; Athar N. Malik, MD, PhD8; Matthew J. Resnick, MD, MPH3,9
January 28, 2022
Key Points
Question:
To what extent do physician-level variations in the appropriateness or quality of care exist within metropolitan areas, notably among specialists?
Findings
In this cross-sectional study of 8788 physicians across 7 specialties in 5 US metropolitan areas, sizeable physician-level practice pattern variations were evident across 14 common clinical scenarios where practice guidelines and clinical evidence can help discern, on average, the appropriateness or quality of clinical decisions.
Variations were robust to adjustment for patient and area-level characteristics, and measure reliability was generally high.
Meaning
Within-area physician-level variations in practice patterns were qualitatively similar across clinical scenarios, despite practice guidelines designed to reduce variation.
Abstract
Importance
While variations in quality of care have been described between US regions, physician-level practice pattern variations within regions remain poorly understood, notably among specialists.
Objective
To examine within-area physician-level variations in decision-making in common clinical scenarios where guidelines specifying appropriateness or quality of care exist.
Design, Setting, and Participants
This cross-sectional study used 2016 through 2019 data from a large nationwide network of commercial insurers, provided by Health Intelligence Company, LLC, within 5 metropolitan statistical areas (MSAs).
Physician-level variations in appropriateness and quality of care were measured using 14 common clinical scenarios involving 7 specialties.
The measures were constructed using public quality measure definitions, clinical guidelines, and appropriateness criteria from the clinical literature.
Physician performance was calculated using a multilevel model adjusted for patient age, sex, risk score, and socioeconomic status with physician random effects.
Measure reliability for each physician was calculated using the signal-to-noise approach.
Within-MSA variation was calculated between physician quintiles adjusted for patient attributes, with the first quintile denoting highest quality or appropriateness and the fifth quintile reflecting the opposite.
Data were analyzed March through October 2021.
Main Outcomes and Measures
Fourteen measures of quality or appropriateness of care, with 2 measures each in the domains of cardiology, endocrinology, gastroenterology, pulmonology, obstetrics, orthopedics, and neurosurgery.
Results
A total of 8788 physicians were included across the 5 MSAs, and about 2.5 million unique patient-physician pairs were included in the measures.
Within the 5 MSAs, on average, patients in the measures were 34.7 to 40.7 years old, 49.1% to 52.3% female, had a mean risk score of 0.8 to 1.0, and more likely to have an employer-sponsored insurance plan that was either self-insured or fully insured (59.8% to 97.6%).
Within MSAs, physician-level variations were qualitatively similar across measures.
- For example, statin therapy in patients with coronary artery disease ranged from 54.3% to 70.9% in the first quintile of cardiologists
to 30.5% to 42.6% in the fifth quintile. - Upper endoscopy in patients with gastroesophageal reflux disease without alarm symptoms spanned 14.6% to 16.9% in the first quintile of gastroenterologists
to 28.2% to 33.8% in the fifth quintile. - Among patients with new knee or hip osteoarthritis, 2.1% to 3.4% received arthroscopy in the first quintile of orthopedic surgeons, whereas 25.5% to 30.7% did in the fifth quintile.
- Appropriate prenatal screening among pregnant patients ranged from 82.6% to 93.6% in the first quintile of obstetricians
to 30.9% to 65.7% in the fifth quintile.
Within MSAs, adjusted differences between quintiles approximated unadjusted differences.
Measure reliability, which can reflect consistency and reproducibility, exceeded 70.0% across nearly all measures in all MSAs.
Conclusions and Relevance
In this cross-sectional study of 5 US metropolitan areas, sizeable physician-level practice variations were found across common clinical scenarios and specialties.
Understanding the sources of these variations may inform efforts to improve the value of care.
About the authors & affiliations
Zirui Song, MD, PhD1,2;
Sneha Kannan, MD2;
Robert J. Gambrel, MS, MA3;
Molly Marino, PhD, MPH3;
Muthiah Vaduganathan, MD, MPH4;
Mark A. Clapp, MD, MPH5;
Jacqueline A. Seiglie, MD2,6;
Patricia P. Bloom, MD7;
Athar N. Malik, MD, PhD8;
Matthew J. Resnick, MD, MPH3,9
- 1Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- 2Department of Medicine, Massachusetts General Hospital, Boston
- 3Embold Health, Nashville, Tennessee
- 4Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- 5Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston
- 6Diabetes Unit, Massachusetts General Hospital, Boston
- 7Division of Gastroenterology, University of Michigan, Ann Arbor
- 8Department of Neurosurgery, Massachusetts General Hospital, Boston
- 9Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
Originally published at https://jamanetwork.com
TAGS: Value Based Health Care; Outcomes Based Health Care; Evidence Based Medicine; Evidence Based Guidelines; Waste Reduction in Clinical Variation
