Diagnostic Certainty as a Source of Medical Practice Variation in Coronary Heart Disease: Results from a Cross-National Experiment of Clinical Decision Making
Restricted accessOtherFirst published online September, 2009
Diagnostic Certainty as a Source of Medical Practice Variation in Coronary Heart Disease: Results from a Cross-National Experiment of Clinical Decision Making
The authors examined physician diagnostic certainty as one reason for cross-national medical practice variation. Data are from a factorial experiment conducted in the United States, the United Kingdom, and Germany, estimating 384 generalist physicians’ diagnostic and treatment decisions for videotaped vignettes of actor patients depicting a presentation consistent with coronary heart disease (CHD). Despite identical vignette presentations, the authors observed significant differences across health care systems, with US physicians being the most certain and German physicians the least certain (P < 0.0001). Physicians were least certain of a CHD diagnoses when patients were younger and female (P < 0.0086), and there was additional variation by health care system (as represented by country) depending on patient age (P < 0.0100) and race (P < 0.0021). Certainty was positively correlated with several clinical actions, including test ordering, prescriptions, referrals to specialists, and time to follow-up.
Institute of Medicine.Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academies Press; 2003.
2.
Ayanian JZ, Epstein AMDifferences in the use of procedures between women and men hospitalized for coronary heart disease. N Engl J Med. 1991 ;325:221-5.
3.
Schwartz LM, Fisher ES, Tosteson NA, et al. Treatment and health outcomes of women and men in a cohort with coronary artery disease. Arch Intern Med. 1997;157:1545-51.
4.
Popescu I., Vaughan-Sarrazin MS, Rosenthal GEDifferences in mortality and use of revascularization in black and white patients with acute MI admitted to hospitals with and without revascularization services . JAMA. 2007;297:2489-95.
5.
Holmes JS, Arispe IE, Moy E.Heart disease and prevention: race and age differences in heart disease prevention, treatment, and mortality. Med Care. 2005;43(suppl):133-41.
6.
James TL, Feldman J., Mehta SDPhysician variability in history taking when evaluating patients presenting with chest pain in the emergency department. Acad Emerg Med . 2006;13:147-52.
7.
Martin R., Gordon EE, Lounsbury P.Gender disparities in the attribution of cardiac-related symptoms: contribution of common sense models of illness. Health Psychol. 1998;17:346-57.
8.
McKinlay JB, Potter DA, Feldman HANon-medical influences on medical decision-making. Soc Sci Med. 1996;42:769-76.
9.
Armstrong DL , Strogatz D., Wang R.United States coronary mortality trends and community services associated with occupational structure, among blacks and whites, 1984-1998. Soc Sci Med. 2004;58:2349-61.
10.
Fincher C., Williams JE, MacLean V., Allison JJ, Kiefe CI, Canto J.Racial disparities in coronary heart disease: a sociological view of the medical literature on physician bias. Ethn Dis. 2004 ;14: 360-71.
11.
McKinlay JB , Link CL, Freund KM, Marceau LD, O’Donnell AB, Lutfey KESources of variation in physician adherence with clinical guidelines: results from a factorial experiment. J Gen Intern Med. 2007;22:289-96.
12.
Arber S., McKinlay JB, Adams A., Marceau LD, Link CL, O’Donnell ABPatient characteristics and inequalities in doctors’ diagnostic and management strategies relating to CHD: a video-simulation experiment. Soc Sci Med. 2006;62:103-15.
13.
Bird CE, Fremont AM, Bierman AS, et al. Does quality of care for cardiovascular disease and diabetes differ by gender for enrollees in managed care plans? Womens Health Issues. 2007;17:131-8.
14.
Fremont AM, Correa-de-Araujo R., Hayes SNGender disparities in managed care: it’s time for action. Womens Health Issues. 2007;17:116-9.
15.
Wexler DJ, Grant RW, Meigs JB, Nathan DM, Cagliero E.Sex disparities in treatment of cardiac risk factors in patients with type 2 diabetes. Diabetes Care. 2005;28:514-20.
16.
Britt H., Bhasale A., Miles DA, Meza A., Sayer GP, Angelis M.The sex of the general practitioner: a comparison of characteristics, patients, and medical conditions managed. Med Care. 1996; 34:403-15.
17.
Collins E., Katona C., Orrell M.Management of depression in the elderly by general practitioners: II. Attitudes to ageing and factors affecting practice. Fam Pract. 1995;12:12-7.
18.
Armstrong D. , Fry J., Armstrong P.Doctors’ perceptions of pressure from patients for referral. BMJ. 1991;302:1186-8.
19.
Curoe A., Kralewski J., Kaissi A.Assessing the cultures of medical group practices. J Am Board Fam Pract. 2003;16:394-8.
20.
Brook RH, Park RE, Chassin MR, Kosecoff J., Keesey J., Solomon D.Do Patient, Physician, and Hospital Characteristics Affect Appropriateness and Outcome of Selected Procedures?Santa Monica, CA: RAND; 1991.
21.
Goodman DC, Grumbach K.Does having more physicians lead to better health system performance? JAMA. 2008;299: 335-7.
22.
Wennberg JE , Fisher ES, Skinner JSGeography and the debate over Medicare reform . Health Aff (Millwood). 2002;Suppl Web Exclusives:W96-114.
23.
Weisz D., Gusmano MK, Rodwin VGGender and the treatment of heart disease in older persons in the United States, France, and England: a comparative, population-based view of a clinical phenomenon . Gend Med. 2004;1:29-40.
24.
Pilote L., Saynina O., Lavoie F., McClellan M.Cardiac procedure use and outcomes in elderly patients with acute myocardial infarction in the United States and Quebec, Canada, 1988 to 1994. Med Care. 2003;41:813-22.
25.
McKinlay J. , Link C., Arber S., et al. How do doctors in different countries manage the same patient? Results of a factorial experiment. Health Serv Res. 2006;41:2182-200. [Erratum in 41(6): 2303.]
26.
Gurjeva OS, Bukhman G., Murphy S., Cannon CPTreatment and outcomes of eastern Europeans with coronary syndromes in OPUS-TIMI 16. Int J Cardiol. 2005;100:101-7.
27.
Kramer JM, Newby LK, Chang WC, et al. International variation in the use of evidence-based medicines for acute coronary syndromes. Eur Heart J. 2003;24:2133-41.
28.
Pauker SG, Kassirer JPThe threshold approach to clinical decision making. N Engl J Med. 1980;302:1109-17.
van Ryn M.Research on the provider contribution to race/ethnicity disparities in medical care. Med Care. 2002;40(suppl): 1140-51.
31.
Balsa AI, McGuire TG, Meredith LSTesting for statistical discrimination in health care. Health Serv Res. 2005;40:227-52.
32.
Lutfey KE, Ketcham JDPatient and provider assessments of adherence and the sources of disparities: evidence from diabetes care. Health Serv Res. 2005;40(pt 1):1803-17.
33.
Villaire M. , Mayer G.Chronic illness management and health literacy: an overview. J Med Pract Manage. 2007;23:177-81.
34.
Safeer RS, Keenan J.Health literacy: the gap between physicians and patients. Am Fam Physician. 2005;72:463-8.
35.
Bittner V.Angina pectoris: reversal of the gender gap. Circulation. 2008;117:1505-7.
36.
Hemingway H., Langenberg C., Damant J., Frost C., Pyorala K., Barrett-Connor E.Prevalence of angina in women versus men: a systematic review and meta-analysis of international variations across 31 countries. Circulation . 2008;117:1526-36.
37.
Shaw LJ, Lewis JF, Hlatky MA, et al. Women’s ischemic syndrome evaluation: current status and future research directions: report of the National Heart, Lung and Blood Institute workshop: October 2-4, 2002: Section 5: gender-related risk factors for ischemic heart disease. Circulation. 2004;109:e56-8.
38.
McKinlay JBSome contributions from the social system to gender inequalities in heart disease. J Health Soc Behav. 1996;37: 1-26.
39.
Marrugat J., Gil M., Sala J.Sex differences in survival rates after acute myocardial infarction. J Cardiovasc Risk. 1999;6:89-97.
40.
Light DWUniversal health care: lessons from theBritish experience. Am J Public Health. 2003;93:25-30.
41.
Altenstetter C.Insights from health care in Germany. Am J Public Health. 2003;93:38-44.
42.
Fisher RAStatistical Methods, Experimental Design and Scientific Inference. New York: Oxford University Press; 1990.
43.
Cohen JW, Krauss NASpending and service use among people with the fifteen most costly medical conditions. Health Affairs. 2003;22:129-38.
44.
Arber S., McKinlay JB, Adams A., Marceau LD, Link CL, O’Donnell ABInfluence of patient characteristics on doctors’ questioning and lifestyle advice for coronary heart disease: a UK/ US video experiment. Br J Gen Pract. 2004;54:673-8.
45.
Balsa AI, McGuire TGStatistical discrimination in health care. J Health Econ. 2001;20:881-907.
46.
Lutfey KE, Link CL, Grant RW, Marceau LD, McKinlay JBIs certainty more important than diagnosis for understanding race and gender disparities? An experiment using coronary heart disease and depression case vignettes. Health Policy. In press.
47.
Staniland JR , Clamp SE, de Dombal FT, et al. Presentation and diagnosis of patients with acute abdominal pain: comparisons between Leeds, U.K. and Akershus county, Norway. Ann Chir Gynaecol. 1980;69:245-50.
48.
Wigton RSSocial judgement theory and medical judgement. Thinking Reasoning . 1996;2:175-90.
49.
Campbell S. , Reeves D., Kontopantelis E., Middleton E., Sibbald B., Roland M.Quality of primary care in England with the introduction of pay for performance. N Engl J Med. 2007;357: 181-90.
50.
Veloski J., Tai S., Evans AS, Nash DBClinical vignette-based surveys: a tool for assessing physician practice variation . Am J Med Qual. 2005;20:151-7.
51.
Peabody JW, Luck J., Glassman P., Dresselhaus TR, Lee M.Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality. JAMA . 2000;283:1715-22.
52.
Dresselhaus TR, Peabody JW, Lee M., Wang MM, Luck J.Measuring compliance with preventive care guidelines: standardized patients, clinical vignettes, and the medical record . J Gen Intern Med. 2000;15:782-8.
53.
Robra BP, Kania H., Kuss O., Schonfisch K., Swart E.[Determinants of hospital admission: investigation by case vignettes]. Gesundheitswesen. 2006;68:32-40.
54.
Brooks LR, LeBlanc VR, Norman GROn the difficulty of noticing obvious features in patient appearance. Psychol Sci. 2000;11:112-7.
55.
Eva KW, Brooks LRThe underweighting of implicitly generated diagnoses. Acad Med. 2000;75(suppl):81-3.
56.
Lutfey KE, Eva KW, Gerstenberger E., Link CL, McKinlay JBThe cognitive basis of diagnostic and treatment disparities in coronary heart disease: results of a factorial experiment. Unpublished manuscript, 2008.
