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Do physicians do what they say? The inclination to test and its association with coronary angiography rates
D E Wennberg1, J D Dickens, L Biener
1Maine Medical Assessment Foundation, Augusta 04351-0249, USA.
Insights
Physician testing intensity for coronary artery disease correlates with coronary angiography rates. This "medical signature" suggests physician inclination influences cardiac procedure utilization across specialties.
Area of Science:
- Cardiology
- Health Services Research
- Medical Decision Making
Background:
- Variations in cardiac procedure utilization are often attributed to patient factors and healthcare systems.
- Physician decision-making and testing intensity are critical, yet less understood, drivers of these variations.
Purpose of the Study:
- To investigate the influence of physicians' inclination to order diagnostic tests on the utilization patterns of cardiac procedures for patients with coronary artery disease.
- To determine if physician testing intensity correlates with population-based coronary angiography rates.
Main Methods:
- A survey of 263 physicians (family practitioners, internists, cardiologists) in Maine, New Hampshire, and Vermont assessed testing inclinations using patient scenarios.
- Developed Catheterization, Imaging Exercise Tolerance Test (ETT), and Nonimaging ETT indices based on self-reported testing intensity.
- Correlated physician index scores with age- and gender-adjusted, population-based coronary angiography rates in different practice areas.
Main Results:
- A significant positive relationship was found between population-based coronary angiography rates and physician scores on the Catheterization Index (p < .005) and Imaging ETT Index (p = .01).
- No significant relationship was observed for the Non-imaging ETT Index (p = .10).
- These associations were present in cardiologists and internists but not family practitioners.
Conclusions:
- Physician self-reported testing intensity is demonstrably linked to population-based coronary angiography rates.
- This relationship suggests a consistent "medical signature" in how physicians evaluate coronary artery disease, influencing procedural utilization.
- Findings highlight the importance of physician practice patterns in understanding healthcare utilization variations.
Objective:
Efforts to evaluate variations in cardiac procedures have focused on patient factors and differences in health care delivery systems. We wanted to assess how physicians' inclination to test patients with coronary artery disease influences utilization patterns.
Setting And Subjects:
Physicians and the populations of Maine, New Hampshire, and Vermont.
Design:
We conducted a survey of 263 family practitioners, internists, and cardiologists residing in 57 hospital service areas in Maine, New Hampshire, and Vermont. Using patient scenarios, we assessed the clinicians' inclinations to test during the evaluation of patients with coronary artery disease. Self-reported testing intensities were used to create three indices: a Catheterization Index, an Imaging Exercise Tolerance Test (ETT) Index, and Nonimaging ETT Index. Using administrative data, age- and gender-adjusted population-based coronary angiography rates were calculated. Physicians were assigned to low (2.9/1,000), average (4.2/1,000), and high (5.8/1,000) coronary angiography rate areas, based on where they practice. Analysis of variance techniques were used to assess the relation of the index scores to the population-based coronary angiography rates and to physician specialties.
Results:
There was a positive relationship between the population-based coronary angiography rates and the self-reported scores of the Catheterization Index (p < .005) and the Imaging ETT Index (p = .01), but none was found for the Non-imaging ETT Index (p = .10). These relationships were evident in subanalyses of cardiologists and internists, but not of family practitioners.
Conclusions:
Self-reported testing intensity by physicians is related to the population-based rates of coronary angiography. This relationship cuts across specialties, suggesting that there is a "medical signature" for the evaluation of patients with coronary artery disease.