How Are Patient Characteristics Relevant for Physicians' Clinical Decision Making in Diabetes?: An Analysis of Qualitative Results from a Cross-National Factorial Experiment

New England Research Institutes, Institute for Community Health Studies, 9 Galen Street, Watertown, MA 02472, United States.
Social Science & Medicine (Impact Factor: 2.89). 09/2008; 67(9):1391-9. DOI: 10.1016/j.socscimed.2008.07.005
Source: PubMed


Variations in medical practice have been widely documented and are a linchpin in explanations of health disparities. Evidence shows that clinical decision making varies according to patient, provider and health system characteristics. However, less is known about the processes underlying these aggregate associations and how physicians interpret various patient attributes. Verbal protocol analysis (otherwise known as 'think-aloud') techniques were used to analyze open-ended data from 244 physicians to examine which patient characteristics physicians identify as relevant for their decision making. Data are from a vignette-based factorial experiment measuring the effects of: (a) patient attributes (age, gender, race and socioeconomic status); (b) physician characteristics (gender and years of clinical experience); and (c) features of the healthcare system in two countries (USA, United Kingdom) on clinical decision making for diabetes. We find that physicians used patients' demographic characteristics only as a starting point in their assessments, and proceeded to make detailed assessments about cognitive ability, motivation, social support and other factors they consider predictive of adherence with medical recommendations and therefore relevant to treatment decisions. These non-medical characteristics of patients were mentioned with much greater consistency than traditional biophysiologic markers of risk such as race, gender, and age. Types of explanations identified varied somewhat according to patient characteristics and to the country in which the interview took place. Results show that basic demographic characteristics are inadequate to the task of capturing information physicians draw from doctor-patient encounters, and that in order to fully understand differential clinical decision making there is a need to move beyond documentation of aggregate associations and further explore the mental and social processes at work.

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Available from: Karen Lutfey Spencer, Apr 03, 2015
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    • "In addition, many occupational therapists provide or limit their services in proportion to the financial status of the clients. Kuipers (14) and Lutfey (15) argued that some demographic features of clients influence health professional decision making. Further research is required about the importance of this factor in clinical reasoning. "
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    • "However, we found that white physicians in our study did not rely on race as a determinant for treatment decision-making. Other studies agree with this, finding that among a largely white physician population, doctors rarely mentioned race and ethnicity to determine clinical assessments [19]. Moreover, while black physicians indicated using race as a proxy for disease risk, black physicians held nuanced and complex views about the appropriate context in which race should be used (e.g. to determine appropriate medication and to understand social determinants of health linked with stress and health disparities). "
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    • "In order to make cross-country comparisons using balanced data, the results presented here are based on a subset of the larger dataset restricted to black and white patients from the USA and UK (N = 256, 64 in each cell). While patient characteristics were an important component of the larger experiment, the present article is focused on cross-national comparisons; in order to maintain adequate cell sizes for making such comparisons, we do not separately address patient attributes in this piece (see Lutfey et al., 2008 for analyses of differences by patient characteristics). "
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    ABSTRACT: A proliferating literature documents cross-national variation in medical practice and seeks to explain observed differences in terms of the presence of certain kinds of healthcare systems, economic, and cultural differences between countries. Less is known about how providers themselves understand these influences and perceive them as relevant to their clinical work. Using qualitative data from a cross-national factorial experiment in the United States and United Kingdom, we analyze 244 primary care physicians' explanations of how organizational features of their respective healthcare settings influence the treatment decisions they made for a vignette patient, including affordability of care; within-system quality deficits; and constraints due to patient behavior. While many differences are attributed to financial constraints deriving from two very differently structured healthcare systems, in other ways they are reflections of cultural and historical expectations regarding medical care, or interactions between the two. Implications, including possible challenges to the implementation of universal care in the USA, are discussed.
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