What's behind the white coat: Potential mechanisms of physician-attributable variation in critical care.

Kuldeep N Yadav,Nicole B Gabler,Joanna L Hart,Michael Josephs,Michael E Detsky,Scott D Halpern,Shane Patman

doi:10.1371/journal.pone.0216418

Kuldeep N Yadav, Nicole B Gabler + Show 5 more

Open Access

https://doi.org/10.1371/journal.pone.0216418

Copy DOI

Abstract

BackgroundCritical care intensity is known to vary across regions and centers, yet the mechanisms remain unidentified. Physician behaviors have been implicated in the variability of intensive care near the end of life, but physician characteristics that may underlie this association have not been determined.PurposeWe sought to identify behavioral attributes that vary among intensivists to generate hypotheses for mechanisms of intensivist-attributable variation in critical care delivery.MethodsWe administered a questionnaire to intensivists who participated in a prior cohort study in which intensivists made prognostic estimates. We evaluated the degree to which scores on six attribute measures varied across intensivists. Measures were selected for their relevance to preference-sensitive critical care: a modified End-of-Life Preferences (EOLP) scale, Life Orientation Test–Revised (LOT-R), Jefferson Scale of Empathy (JSE), Physicians' Reactions to Uncertainty (PRU) scale, Collett-Lester Fear of Death (CLFOD) scale, and a test of omission bias. We conducted regression analyses assessing relationships between intensivists’ attribute scores and their prognostic accuracy, as physicians’ prognostic accuracy may influence preference-sensitive decisions.Results20 of 25 eligible intensivists (80%) completed the questionnaire. Intensivists’ scores on the EOLP, LOT-R, PRU, CLFOD, and omission bias measures varied considerably, while their responses on the JSE scale did not. There were no consistent associations between attribute scores and prognostic accuracy.ConclusionsIntensivists vary in feasibly measurable attributes relevant to preference-sensitive critical care delivery. These attributes represent candidates for future research aimed at identifying mechanisms of clinician-attributable variation in critical care and developing effective interventions to reduce undue variation.

Highlights

Measures were selected for their relevance to preference-sensitive critical care: a modified End-of-Life Preferences (EOLP) scale, Life Orientation Test–Revised (LOT-R), Jefferson Scale of Empathy (JSE), Physicians’ Reactions to Uncertainty (PRU) scale, Collett-Lester Fear of Death (CLFOD) scale, and a test of omission bias
Intensivists vary in feasibly measurable attributes relevant to preference-sensitive critical care delivery
These attributes represent candidates for future research aimed at identifying mechanisms of clinician-attributable variation in critical care and developing effective interventions to reduce undue variation

Summary

Introduction

Critical care intensity varies across geographic regions and health care centers [1,2,3,4,5]. Physician identity has been shown to more strongly predict patient enrollment in hospice care than patient characteristics [10]. Such physician-attributable variation of care that should be based on patient preferences, values, and goals is inherently problematic. Reducing physician-attributable variation in preference-sensitive health care choices is paramount, yet the mechanisms of such variation remain unclear. Identifying these mechanisms is the first step in a research agenda aimed at developing interventions to reduce this undue variation. We sought to identify behavioral attributes that vary among intensivists to generate hypotheses for mechanisms of intensivist-attributable variation in critical care delivery

Objectives

Methods

Conclusion