Diagnostic Certainty as a Source of Medical Practice Variation in Coronary Heart Disease: Results from a Cross-National Experiment of Clinical Decision Making

New England Research Institutes, Watertown, Massachusetts 02472, USA.
Medical Decision Making (Impact Factor: 3.24). 06/2009; 29(5):606-18. DOI: 10.1177/0272989X09331811
Source: PubMed


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.

Download full-text


Available from: Karen Lutfey Spencer, Apr 03, 2015
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The authors develop a conceptual framework regarding how information technology (IT) can alter within-physician disparities, and they empirically test some of its implications in the context of coronary heart disease. Using a random experiment on 256 primary care physicians, the authors analyze the relationships between three IT functions (feedback and two types of clinical decision support) and five process-of-care measures. Endogeneity is addressed by eliminating unobserved patient characteristics with vignettes and by proxying for omitted physician characteristics. The results indicate that IT has no effects on physicians' diagnostic certainty and treatment of vignette patients overall. The authors find that treatment and certainty differ by patient age, gender, and race. Consistent with the framework, IT's effects on these disparities are complex. Feedback eliminated the gender disparities, but the relationships differed for other IT functions and process measures. Current policies to reduce disparities and increase IT adoption may be in discord.
    Full-text · Article · Jul 2009 · Medical Care Research and Review
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Literature on health disparities documents variations in clinical decision-making across patient characteristics, physician attributes, and among health care systems. Using data from a vignette-based factorial experiment of 256 primary care providers, we examine the cognitive basis of disparities in the diagnosis and treatment of coronary heart disease (CHD). We explore whether previously observed disparities are due to physicians (1) not fully considering CHD for certain patients or (2) considering CHD but then discounting it. Half of the physicians in the experiment were primed with explicit directions to consider a CHD diagnosis, and half were not. Relative to their unprimed counterparts, primed physicians were more likely to order CHD-related tests and prescriptions. However, the main effects for patient gender and age remained, suggesting that physicians treated these demographic variables as diagnostic features indicating lower risk of CHD for these patients. This finding suggests that physician appeals to perceived base rates have the potential to contribute to the further reification of socially constructed health statistics.
    Full-text · Article · Mar 2010 · Journal of Health and Social Behavior
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: International differences in disease prevalence rates are often reported and thought to reflect different lifestyles, genetics, or cultural differences in care-seeking behavior. However, they may also be produced by differences among health care systems. We sought to investigate variation in the diagnosis and management of a "patient" with exactly the same symptoms indicative of depression in 3 different health care systems (Germany, the United Kingdom, and the United States).Method: A factorial experiment was conducted between 2001 and 2006 in which 384 randomly selected primary care physicians viewed a video vignette of a patient presenting with symptoms suggestive of depression. Under the supervision of experienced clinicians, professional actors were trained to realistically portray patients who presented with 7 symptoms of depression: sleep disturbance, decreased interest, guilt, diminished energy, impaired concentration, poor appetite, and psychomotor agitation or retardation.Results: Most physicians listed depression as one of their diagnoses (89.6%), but German physicians were more likely to diagnose depression in women, while British and American physicians were more likely to diagnose depression in men (P = .0251). American physicians were almost twice as likely to prescribe an antidepressant as British physicians (P = .0241). German physicians were significantly more likely to refer the patient to a mental health professional than British or American physicians (P < .0001). German physicians wanted to see the patient in follow-up sooner than British or American physicians (P < .0001).Conclusions: Primary care physicians in different countries diagnose the exact same symptoms of depression differently depending on the patient's gender. There are also significant differences between countries in the management of a patient with symptoms suggestive of depression. International differences in prevalence rates for depression, and perhaps other diseases, may in part result from differences among health care systems in different countries.
    No preview · Article · Jan 2011
Show more