The Association of Physician Attitudes about Uncertainty and Risk Taking with Resource Use in a Medicare HMO

Department of Medicine, University of Alabama at Birmingham, 35294-3296, USA.
Medical Decision Making (Impact Factor: 3.24). 08/1998; 18(3). DOI: 10.1177/0272989X9801800310
Source: PubMed


PURPOSE: To explore the association between the attitudes of primary care physicians toward uncertainty and risk taking, as measured by a validated survey, with resource use in a Medicare HMO.
DESIGN: All primary-care internists (n=20) in a large, multi-specialty clinic were surveyed to measure their attitudes about uncertainty and risk taking using three previously developed scales. Results were linked with administrative data for 792 consecutive patients in a recently created Medicare HMO. The patients' index visits occurred between April 1, 1995, and November 30, 1995.
ANALYSIS: Charges stemming from several claim types (primary care and subspecialty physician, laboratory, radiology, and ambulatory procedures) in the 30 days following the index visit were summed. The physician scales were dichotomized at the median to seek unadjusted associations with charges. Generalized estimation equations were used to account for the correlation of charges resulting from patients' being nested within physicians and adjusted for physician characteristics (age, sex, years in practice) and patient characteristics (age, sex, comorbidity).
MAIN RESULTS: The physician response rate was 90%. Most physicians (90%) were male. The mean age of the patients was 74 years, and 69% were female. The mean cost (+/-SD) per patient was $621.61+/-1,737.31. From the unadjusted analysis, high "anxiety due to uncertainty" was associated with higher patient charges ($197.85 vs $158.21, p=0.01). From the multivariable analysis, each standard deviation increase in "anxiety due to uncertainty" (3.5 points) corresponded to a 17% increase in mean charges (p < 0.01) and each similar increase in "reluctance to disclose uncertainty to patients" (1.92 points) corresponded to a 12% increase (p=0.03). However, increasing "reluctance to disclose mistakes to physicians" and increasing physician risk-taking propensity were associated with decreased total charges [-10% per standard deviation (1.34 points), p=0.02, and -8% per standard deviation (3.26 points), p=0.02, respectively].
CONCLUSION: Physician attitudes toward uncertainty were significantly associated with patient charges. Further investigation may improve prediction of patient-care charges, offer insight into the medical decision-making process, and perhaps clarify the relationship between cost, uncertainty, and quality of care.

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    • "Gerrity et al. were the first to develop a validated questionnaire that measures the affective reaction to uncertainty [7], [8]. This questionnaire demonstrated that higher anxiety due to uncertainty is associated with higher resource use [9]. Stolper et al. developed a questionnaire that measures the impact of gut feelings on medical decision-making in terms of ‘sense of alarm’ and ‘sense of reassurance’ [10]. "
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    ABSTRACT: Background Diagnostic reasoning in primary care setting where presented problems and patients are mostly unselected appears as a complex process. The aim was to develop a questionnaire to describe how general practitioners (GPs) deal with uncertainty to gain more insight into the decisional process. The association of personality traits with medical decision making was investigated additionally. Methods Raw items were identified by literature research and focus group. Items were improved by interviewing ten GPs with thinking-aloud-method. A personal case vignette related to a complex and uncertainty situation was introduced. The final questionnaire was administered to 228 GPs in Germany. Factorial validity was calculated with explorative and confirmatory factor analysis. The results of the Communicating and Dealing with Uncertainty (CoDU) – questionnaire were compared with the scales of the ‘Physician Reaction to Uncertainty’ (PRU) questionnaire and with the personality traits which were determined with the Big Five Inventory (BFI-K). Results The items could be assigned to four scales with varying internal consistency, namely ‘communicating uncertainty’ (Cronbach alpha 0.79), ‘diagnostic action’ (0.60), ‘intuition’ (0.39) and ‘extended social anamnesis’ (0.69). Neuroticism was positively associated with all PRU scales ‘anxiety due to uncertainty’ (Pearson correlation 0.487), ‘concerns about bad outcomes’ (0.488), ‘reluctance to disclose uncertainty to patients’ (0.287), ‘reluctance to disclose mistakes to physicians’ (0.212) and negatively associated with the CoDU scale ‘communicating uncertainty’ (−0.242) (p<0.01 for all). ‘Extraversion’ (0.146; p<0.05), ‘agreeableness’ (0.145, p<0.05), ‘conscientiousness’ (0.168, p<0.05) and ‘openness to experience’ (0.186, p<0.01) were significantly positively associated with ‘communicating uncertainty’. ‘Extraversion’ (0.162), ‘consciousness’ (0.158) and ‘openness to experience’ (0.155) were associated with ‘extended social anamnesis’ (p<0.05). Conclusion The questionnaire allowed describing the diagnostic decision making process of general practitioners in complex situations. Personality traits are associated with diagnostic reasoning and communication with patients, which might be important for medical education and quality improvement purposes.
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    • "Thus, physicians may encounter very complex situations, as they tend to patients whose treatments and diagnoses reflect a wide continuum of ambiguity. As Geller (2013) summarized, physicians who have a low tolerance of ambiguity are more likely to recall mammograms [6], increase patient charges [7], withhold negative genetic test results [8], fear malpractice litigation, and thus engage in defensive practice [9], experience discomfort in the context of death and grief [10], exhibit greater test-ordering tendencies, and demonstrate failure to comply with evidence-based guidelines [11]. "
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    ABSTRACT: Tolerance of ambiguity, or the extent to which ambiguous situations are perceived as desirable, is an important component of the attitudes and behaviors of medical students. However, few studies have compared this trait across the years of medical school. General practitioners are considered to have a higher ambiguity tolerance than specialists. We compared ambiguity tolerance between general practitioners and medical students. We designed a cross-sectional study to evaluate the ambiguity tolerance of 622 medical students in the first to sixth academic years. We compared this with the ambiguity tolerance of 30 general practitioners. We used the inventory for measuring ambiguity tolerance (IMA) developed by Reis (1997), which includes three measures of ambiguity tolerance: openness to new experiences, social conflicts, and perception of insoluble problems. We obtained a total of 564 complete data sets (return rate 90.1%) from medical students and 29 questionnaires (return rate 96.7%) from general practitioners. In relation to the reference groups defined by Reis (1997), medical students had poor ambiguity tolerance on all three scales. No differences were found between those in the first and the sixth academic years, although we did observe gender-specific differences in ambiguity tolerance. We found no differences in ambiguity tolerance between general practitioners and medical students. The ambiguity tolerance of the students that we assessed was below average, and appeared to be stable throughout the course of their studies. In contrast to our expectations, the general practitioners did not have a higher level of ambiguity tolerance than the students did.
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    • "Frank et al. (2000) encontraron que la aversión al riesgo está positiva y significativamente asociada con la probabilidad de remitencia en atención básica o cuidado primario, una vez excluidos los factores asociados a la práctica médica. De otro lado, Baldwin et al. (2005) no encontraron evidencia de que el incremento en la tasa de admisiones per cápita por bronquiolitis se explicara por la tolerancia al riesgo o el malestar a la incertidumbre de los médicos encargados de este tipo de casos, medida por la escala de Gerrity et al. Allison et al. (1998) estudiaron la asociación entre las actitudes frente a la "
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    ABSTRACT: Se realiza una revisión de literatura sobre la aversión al riesgo en la toma de decisiones médicas. Se presenta la aversión al riesgo desde las teorías de la utilidad esperada subjetiva y desde la utilidad esperada basada en rangos. Se revisan las metodologías de medición de la aversión al riesgo en situaciones clínicas desde la economía y desde la psicología.
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