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Variations in Physician Practice Style and Outcomes of Care

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Principal Investigator: John Ware, Jr., Ph.D., The New England Medical Center.
Grant Number: HS 06073.
Project Period: January 1988 to December 1991.


Differences in the effectiveness of medical and surgical procedures and drugs are not the only factors behind variations in patient care. Where a physician practices, his or her training, and interpersonal style, or bedside manner, also affect patient outcomes and health care costs.


Variations in Physician Practices Contents (Summer 1994)

Introduction

Supported by AHCPR, this study expands on the work of the national Medical Outcomes Study of more than 20,000 adults in Chicago, Boston, and Los Angeles, who received care from primary care and specialty physicians for one or more chronic conditions: hypertension, coronary heart disease, diabetes, and depression. Variations in physician practice style and patient outcomes were examined in three systems of care: health maintenance organizations (HMOs), multispecialty groups, and solo practices.

Practice style involved resource use such as inpatient and outpatient visits, referrals, tests ordered, procedures done, and medications prescribed. Also included were interpersonal issues such as the provider's manner with patients, counseling and communication skills, and the level of patient participation in care and treatment decisions. An important focus was patients' perceptions of their general health and well-being, their ability to function in everyday living, and their satisfaction with treatment.

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Findings

Among the findings published to date are the following:

  • Patients insured through fee-for-service insurance plans and treated by single-specialty physicians in solo practice were hospitalized 40 percent more than were HMO patients.
  • HMO patients had 8 percent fewer physician visits than did fee-for-service patients of single-specialty doctors in solo practice; these patients also took 12 percent fewer prescription drugs.
  • Medical specialists prescribe more drugs and tests than do primary care physicians, and specialists are more likely to hospitalize patients with the same illnesses and severity levels.
  • HMO physicians order fewer tests than do physicians in solo practice and group practice; they are also less likely to hospitalize their patients.
  • Patients who rated their health as poor in the SF-36 questionnaire developed as part of the study used 10 times more hospital care than those who rated their health as excellent.

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Dissemination

Results of this study have been published in the Journal of the American Medical Association, Archives of Internal Medicine, Archives of General Psychiatry, Journal of Gerontology, Psychiatric Medicine, Cancer, Quality of Life Research, Medical Care, and at least 11 other professional journals and books.

Dissemination Summary: Variations in Physician Style and Outcomes of Care

Presentations: 39
Professional Articles: 30
Health Industry Articles: 2
Editorials/Mentions: 14
Consumer Print: 14
Consumer Broadcast: 0
Total: 99

Given the role of quality of care in health care reform proposals now before Congress, this AHCPR-funded study has drawn the attention of the daily press. Newspapers such as the Wall Street Journal, New York Times, and Chicago Tribune have written about the study, particularly about its development of the SF-36 questionnaire. The questionnaire asks patients to rate their quality of life in terms of physical functional ability, social functional ability, role limitations due to physical problems, degree of bodily pain, mental health status, role limitations due to emotional problems, vitality, and general health perceptions.

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Implications

Understanding key factors for better patient outcomes would allow those elements of care to be emphasized in managed systems with cost constraints. How patients fare with aggressive (and usually more expensive) treatment or conservative approaches is central to the debate. Practical tools to monitor patient health, such as an easy-to-use questionnaire with reliable results, could yield better feedback for providers or help predict health needs. Such tools are also needed to assess new drugs and treatments, health care quality, and the health organizations that provide care.

The significance of interpersonal aspects of care to health outcomes could shift part of the health policy debate to the need for better training of practitioners in these areas. Interpersonal style has been linked to noncompliance with medical regimens, disenrollments from group practices, and doctor-shopping.

This study also draws attention to the mix of physicians providing health care and how they are organized—in HMOs, multispecialty groups, and solo practices. It may fuel concerns over a lack of primary care doctors and a surplus of specialists, especially if the United States moves toward a system of managed care networks in which generalists serve as gatekeepers in making referrals to specialists. An important question for further analysis will be whether reduced use of health services by HMOs affects the health outcomes of chronically ill patients.

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Bibliography

DiMatteo, M. R., Sherbourne, C. D., Hays, R. D., Ordway, L., Kravitz, R. L., McGlynn, E. A., Kaplan, S., and Rogers, W. H. (1993). Physicians' characteristics influence patients' adherence to medical treatment: Results from the Medical Outcomes Study. Health Psychology 12(2), 93-102.

Greenfield, S., and Nelson, E. C. (1992). Recent developments and future issues in the use of health status assessment measures in clinical settings. Medical Care 30(5 Suppl), MS23-MS41.

Greenfield, S., Nelson, E. C., Zubkoff, M., Manning, W., Rogers, W., Kravitz, R., Keller, A., Tarlov, A. R., and Ware, J. E. (1992). Variations in resource utilization among medical specialties and systems of care. Results from the Medical Outcomes Study. Journal of the American Medical Association 267(12), 1624-1630.

Hays, R. D., Hayashi, T., and Stewart, A. L. (1989). A five-item measure of socially desirable response set. Educational and Psychological Measurement 49, 629-636.

Hays, R. D., Marshall, G. N., Wang, E. Y., and Sherbourne, C. D. (in press). Four-year cross-lagged associations between physical and mental health in the Medical Outcomes Study. Journal of Consulting and Clinical Psychology.

Hays, R. D., and Stewart, A. L. (1990). The structure of self-reported health in chronic disease patients. Psychological Assessment: A Journal of Consulting and Clinical Psychology 2(1), 22-30.

Kravitz, R. L., Greenfield, S., Rogers, W., Manning, W., Zubkoff, M., Nelson, E. C., Tarlov, A. R., and Ware, J. (1992). Differences in the mix of patients among medical specialties and systems of care. Results from the Medical Outcomes Study. Journal of the American Medical Association 267(12), 1617-1623.

Kravitz, R. L., Hays, R. D., Sherbourne, C. D., DiMatteo, M. R., Rogers, W. H., Ordway, L., and Greenfield, S. (1993). Recall of recommendations and adherence to advice among patients with chronic medical conditions. Archives of Internal Medicine 153, 1869-1878.

McHorney, C. A., Ware, J. E., Lu, J. F. R., and Sherbourne, C. D. (in press). The MOS 36-item short-form health survey (SF-36): III. Tests of data quality, scaling assumptions and reliability across diverse patient groups. Medical Care.

McHorney, C. A., Ware, J. E., and Raczek, A. E. (1993). The MOS 36-item short-form health survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical Care 31(3), 247-263.

McHorney, C. A., Ware, J. E., Rogers, W., Raczek, A. E., and Lu, J. F. R. (1992). Validity and relative precision of MOS short- and long-form health status scales and Dartmouth COOP charts. Medical Care 30(5 Suppl), MS253-MS265.

Rogers, W. H., Wells, K. B., Meredith, L. S., Strum, R., and Burnham, M. A. (1993). Outcomes for adult outpatients with depression under prepaid or fee-for-service financing. Archives of General Psychiatry 50(7), 517-525.

Rubin, H. R., Gandek, B., Kosinski, M., Rogers, W. H., McHorney, C. A., and Ware, J. E. (1993). Patient ratings of outpatient visits in different practice settings: Results from the Medical Outcomes Study. Journal of the American Medical Association 270(7), 835-840.

Sherbourne, C. D., and Hays, R. D. (1990). Marital status, social support, and health transitions in chronic disease patients. Journal of Health and Social Behavior 31(4), 328-339.

Sherbourne, C. D., Hays, R. D., Ordway, L., DiMatteo, M. R., and Kravitz, R. L. (1992). Antecedents of adherence to medical recommendations: Results from the Medical Outcomes Study. Journal of Behavioral Medicine 15(5), 447-469.

Sherbourne, C. D., and Meredith, L. S. (1992). Quality of self-report data: A comparison of older and younger chronically ill patients. Journal of Gerontology: Social Sciences 47(4), S204-S211.

Sherbourne, C. D., Meredith, L. S., Rogers, W., and Ware, J. E. (1992). Social support and stressful life events: Age differences in their effects on health-related quality of life among the chronically ill. Quality of Life Research 1(4), 235-245.

Sherbourne, C. D., and Stewart, A. L. (1991). The MOS social support survey. Social Science Medicine (Great Britain) 32(6), 705-714.

Stewart, A. L., Greenfield, S., Hays, R. D., Wells, K., Rogers, W. H., Berry, S. D., McGlynn, E. A., and Ware, J. E. (1989). Functional status and well-being of patients with chronic conditions. Results from the Medical Outcomes Study. Journal of the American Medical Association 262(7), 907-913.

Stewart, A. L., and Ware, J. E. (1992). In Measuring Functioning and Well-Being: The Medical Outcomes Study Approach. Durham, NC: Duke University Press.

Tarlov, A. R., Ware, J. E., Greenfield, S., Nelson, E. C., Perrin, E., and Zubkoff, M. (1989). The Medical Outcomes Study. An application of methods for monitoring the results of medical care. Journal of the American Medical Association 262(7), 925-930.

Ware, J. E. (1990). Measuring patient function and well-being: Some lessons from the Medical Outcomes Study. In K. A. Heitoff and K. N. Lohr (Eds.), Effectiveness and Outcomes in Health Care (pp. 107-119). National Academy Press.

Ware, J. E. (1990). Outcomes study foresees greater patient input. QA Review (p. 5).

Ware, J. E. (1991). Conceptualizing and measuring generic health outcomes. Cancer 67(Suppl), 774-779.

Ware, J. E. (1991). Measuring functioning, well-being and other generic health concepts. In D. Osoba (Ed.), The Effect of Cancer on Quality of Life (pp. 8-23). CRC Press.

Ware, J. E. (in press). Measuring health status. Annual Review of Public Health.

Ware, J. E., and Sherbourne, C. D. (1992). The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care 30(6), 473-481.

Wells, K. B., and Burnam, M. A. (1991). Caring for depression in America: Lessons learned from early finding of the Medical Outcomes Study. Psychiatric Medicine 9(4), 503-519.

Wells, K. B., Burnam, M. A., Rogers, W., Hays, R., and Camp, P. (1992). The course of depression in adult outpatients: Results from the Medical Outcomes Study. Archives of General Psychiatry 49, 788-794.

Wells, K. B., Hays, R. D., Burnham, M. A., Rogers, W., Greenfield, S., and Ware, J. E. (1989). Detection of depressive disorder for patients receiving patients receiving prepaid or fee for service care: Results from the Medical Outcomes Study. Journal of the American Medical Association 262(23), 3298-3302.

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