Variation In Practice Style Research Articles

The economic consequences of practice style variation in providing medical interventions: A systematic review of the literature.

The practice style variation (PSV) incurs undesirable clinical and economic consequences for patients and the healthcare system. This review aims to analyze the economic consequences of PSV in medical interventions. A comprehensive electronic search was conducted through PubMed, Web of Sciences, EBSCO, EMBASE, and Cochrane databases to retrieve studies on economic consequences of PSV within 1975–2018. The studies were independently assessed by two reviewers. The quality of studies was assessed by Strengthening the Reporting of Observational Studies in Epidemiology checklist. No language restriction was applied. Only four studies met the eligibility criteria. These studies have been conducted retrospectively in developed countries. Most of the included studies used consumer demand theory to measure the economic consequences of PSV. Findings showed 12%–74% of all variations in healthcare services are related to PSV, thereby incurring up to 23 million dollars for the healthcare system. The PSV is related to the total expenditure, price elasticity, and coefficient of variation of healthcare services. PSV associated with huge inefficiency and inequity in access to healthcare services. To mitigate the consequences of PSV, policymakers should consider PSV in both developing the medical education plans as well as cost management. Using multilevel analysis to investigate the determinants of PSV would be beneficial.

The clinical and economic consequences of practice style variations in common surgical interventions: A protocol for systematic review.

Background:Surgical intervention is one of the common therapeutic interventions applied to a vast class of diseases. Unwarranted variation in practice style in different locations is considered as practice style variations (PSVs), which cause undesirable effects on patient health status and economic consequences. The magnitude of the variations in surgical interventions and its effects on clinical outcomes of patients and also utilization of resources have been investigated in recent years. But the findings show considerable heterogeneities in magnitude and consequences. We develop a protocol to systematically review the current literature of PSV to explain the magnitude of PSV and its clinical and economic consequences.Method:This systematic review will include observational and experimental studies to investigate magnitude and consequences of PSV in common surgical interventions, cardiovascular disease, urological, and ophthalmological diseases. Source of information is scientific databases, theses, clinical trials registrations website, and grey literature. A comprehensive electronic search will be conducted through PubMed, Web of Science, EBSCO, EMBASE, and Scopus databases. Studies are assessed systematically by 2 investigators. Methodological quality of the included studies is evaluated by the STROBE and CONSORT checklists. In case of data availability, we will pool findings of included studies by meta-analysis techniques in the CMA software. Subgroup analyses are based on the type of the interventions and selected diseases.Results:This study has ethical approval from ethical committee of Iran University of Medical Sciences, ethic code: IR.IUMS.REC1395.9221504203. The results will be published in a peer-reviewed journal.Conclusion:A systematic review is considered as an appropriate scientific method for reaching a consensus on magnitude as well as consequences of PSV. Results of this study will help clinical experts to attain more knowledge about PSV and encourage them to use some tools such as clinical guidelines and shared decision making to alleviate its consequences.

Practice Style Variation in Medicaid and Non-Medicaid Children With Complex Chronic Conditions Undergoing Surgery.

With differential payment between Medicaid and Non-Medicaid services, we asked whether style-of-practice differs between similar Medicaid and Non-Medicaid children with complex chronic conditions (CCCs) undergoing surgery. Surgery in children with CCCs accounts for a disproportionately large percentage of resource utilization at major children's hospitals. A matched cohort design, studying 23,582 pairs of children with CCCs undergoing surgery (Medicaid matched to Non-Medicaid within the same hospital) from 2009 to 2013 in 41 Children's Hospitals. Patients were matched on age, sex, principal procedure, CCCs, and other characteristics. Median cost in Medicaid patients was $21,547 versus $20,527 in Non-Medicaid patients (5.0% higher, P < 0.001). Median paired difference in cost (Medicaid minus Non-Medicaid) was $320 [95% confidence interval (CI): $208, $445], (1.6% higher, P < 0.001). 90th percentile costs were $133,640 versus $127,523, (4.8% higher, P < 0.001). Mean paired difference in length of stay (LOS) was 0.50 days (95% CI: 0.36, 0.65), (P < 0.001). ICU utilization was 2.8% higher (36.7% vs 35.7%, P < 0.001). Finally, in-hospital mortality pooled across all pairs was higher in Medicaid patients (0.38% vs 0.22%, P = 0.002). After adjusting for multiple testing, no individual hospital displayed significant differences in cost between groups, only 1 hospital displayed significant differences in LOS and 1 in ICU utilization. Treatment style differences between Medicaid and Non-Medicaid children were small, suggesting little disparity with in-hospital surgical care for patients with CCCs operated on within Children's Hospitals. However, in-hospital mortality, although rare, was slightly higher in Medicaid patients and merits further investigation.

Gender-specific practice styles and ambulatory health care expenditures.

This paper explores the role of physician gender in the expenditures for ambulatory care as a potential source of practice style variation. We exploit a large doctor-patient panel dataset based on insurance-claims data from Switzerland to estimate the effect of physician gender on health care expenditures. We find considerable heterogeneity across specialties. In primary care, female doctors are found to produce similar overall expenditures per visit as their male colleagues, but significantly smaller prescribing costs and significantly higher laboratory costs. In secondary-care specialties, we find that women generate lower overall expenditures, which is mainly driven by consultation costs. These findings provide evidence for the existence of sex-specific practice styles that translate into different overall expenditures as well as different compositions of these expenditures.

Physician Practice Style Variation-Implications for Policy.

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Developing a neonatal unit ventilation protocol for the preterm baby

Mechanical ventilation is a resource-intensive complex medical intervention associated with high morbidity. Considerable practice style variation exists in most hospitals and is not only confusing for parents, but the lack of consistently high standard of optimal ventilation deprives some infants of the benefits of state-of-the-art care. Developing a unit protocol for mechanical ventilation requires exhaustive research, inclusion of all stake-holders, thoughtful protocol development and careful implementation after a thorough educational process, followed by monitoring. A protocol for respiratory support should be comprehensive, addressing respiratory support in the delivery room, the use of non-invasive support, intubation criteria, surfactant administration, specific ventilation modes and settings, criteria for escalating therapy, weaning protocols, extubation criteria, and post-extubation management. Evidence favors the use of non-invasive support as first line treatment, progressing to assist/control or pressure support ventilation combined with volume guarantee, if needed, and high-frequency ventilation only for specific indications. The open lung strategy is crucial to lung-protective ventilation.

Urologist Practice Styles in the Initial Evaluation of Elderly Men With Benign Prostatic Hyperplasia

To investigate the degree to which expenditures on symptom evaluations vary among urologists and the factors associated with such variation. As the medical and surgical specialists for men with lower urinary tract symptoms (LUTS), urologists provide testing to evaluate symptoms and determine therapy. We developed a cohort of men with an initial urologist visit for benign prostatic hyperplasia (BPH) from a 5% sample of Medicare patients (1999-2007) and established a physician level factor, practice style, as a function of average per patient expenditures. We then determined which AUA BPH guideline elements explained variation in quantity and expenditures for BPH testing, and also examined the impact of patient and physician factors on practice style. A nearly 15-fold variation in urologists' average per-patient expenditures existed ($35 to $527 per month; Median $92). Practice styles were associated with physician (P < .01 all examined variables) and patient (P < .01 for comorbidity, race/ethnicity, and socioeconomic status) factors. Guideline recommended care was provided at lower rates by the lowest expenditure urologists compared with middle- to highest-intensity urologists (P < .01). Practice style variations were attributable mainly to differences in tests characterized by the guidelines as optional and not-recommended (P < .01). Expenditures for BPH evaluations vary substantially by geography, practice setting, and experience and are accounted for largely by differences in the use of optional and not-routinely recommended tests. Greater standardization could enhance patient care and reduce health care costs.

Comparing the importance of disease rate versus practice style variations in explaining differences in small area hospitalization rates for two respiratory conditions.

Many studies have reported large variations in age- and sex-adjusted rates of hospitalizations across small geographic areas. These variations have often been attributed to differences in medical practice style which are not reflected in differences in health care outcomes. There is, however, another potentially important source of variation that has not been examined much in the literature: geographic differences in the age-sex adjusted size of the pool of patients who present with the disease and are candidates for hospitalization. Previous studies of small area variations in hospitalization rates have only used data on hospitalizations. Thus, it has not been possible to distinguish the extent to which differences in hospitalization rates are due to (i). differences in the chance that patients diagnosed with a disease are admitted to a hospital, which we refer to as the 'practice style effect,' versus (ii). geographic differences in the total amount of diagnosed disease, which we refer to as the 'disease effect.' Elementary methods for estimating the relative strength of the two effects directly from the data can be misleading, since equal amounts of variability in each effect result in unequal impacts on hospitalization rates. In this paper we describe a model-based approach for estimating the relative importance of the practice style effect and the disease effect in explaining variations in hospitalization rates. The key to our approach is the use of data on both inpatient and outpatient visits. We use 1997 Medicare data for two respiratory medical conditions across 71 small areas in Massachusetts: chronic bronchitis and emphysema, and bacterial pneumonia. Based on a Poisson model for the process generating hospitalizations and outpatient visits, we use a Bayesian framework and Gibbs sampling to compute and compare the correlation between the number of people hospitalized and each of these two sources of variation. Our results show that for the two conditions, disease rate variation explains at least as much of the variation in hospitalization rates as does practice style variation.

An explanatory model of medical practice variation: a physician resource demand perspective.

Practice style variation, or variation in the manner in which physicians treat patients with a similar disease condition, has been the focus of attention for many years. The research agenda is further intensified by the unrealistic assumption that by reducing variation, quality will be improved, costs will be reduced, or both. There is a wealth of literature that identifies differences in health care use of many kinds, in apparently similar communities. Attempts have been made by many scholars to identify the determinants of variation in terms of differences in the population characteristics (e.g. age, sex, insurance, etc.) and geographical characteristics (e.g. distance to provider, number of physicians, number of hospital beds, etc.). When significant differences in use rates prevail after controlling for differences in population characteristics, it is often attributed to 'uncertainty', or the fact that there is no consensus on what constitutes the optimum treatment process. It is suggested by this literature that the greatest variation can be found in the circumstances where there is the most 'uncertainty'. In this work, a physician resource demand model is proposed in which it is suggested that, during the diagnosis and treatment process, physicians demand resources consistent with the clinical needs of the patients, modified by the intervening forces under which they practice. These intervening forces, or constraints, are categorized as patient agency constraints, organizational constraints and environmental constraints, which are characterized as 'induced variation'. It is suggested that when all of the variables that constitute these constraints are identified, the remaining variance represents 'innate variance', or practice style differences. It is further suggested that the more completely this model is specified, the more likely area differences will be attenuated and the smaller will be the residual variance.

Diagnosing depression and prescribing antidepressants by primary care physicians: the impact of practice style variations.

This study examined variations in the diagnosis of depressive disorders and prescription of antidepressant medications in primary care and the contribution of the physicians' practice styles to these variations. The analyses were based on visits to a representative sample of the U.S. office-based primary care physicians from the 1997 and 1998 National Ambulatory Medical Care Survey. In this sample, the propensities to give a diagnosis of depressive disorder and to prescribe antidepressants were operationalized as propensity variables. The association of these variables, obtained from a randomly selected subsample of visits to each physician, with the diagnoses and treatments of the other patients seen by the same physicians was examined. The results revealed considerable variations across practices in the percentages of patients who received diagnoses of depressive disorders (0-25%) and prescriptions for antidepressant medications (0-38%). Furthermore, the physicians' propensities to diagnose depressive disorders or to prescribe antidepressants were significantly associated with the diagnosis and treatment of individual patients. The large variations in diagnosis and treatment of depressive disorders and the significant impact of practice style variables on these variations highlight the need for implementation of uniform practice guidelines for diagnosis and treatment of depressive disorders in primary care settings.

Capitated payments for mental health patients: a comparison of potential approaches in a public sector population

Background: Both private and public health care systems have embraced capitated reimbursement as a method of controlling costs. Aims of the Study: This study explores the financial implications of using reimbursement models based on clinically based patient classification schemes to distribute funds for the treatment of mental health patients in the Department of Veterans Affairs (VA). Methods: We identified 53700 veterans treated in VA specialty mental health outpatient clinics during the first 2 weeks of fiscal year (FY) 1991 for whom relevant clinical data were available. We calculated total utilization and costs for this sample during the remainder of FY 1991 using VA administrative databases and simulated hypothetical distributions of funds based on seven alternative capitation models. The resulting distributions of funds across service networks and facility types were compared to actual expenditures. Results: Approximately 8% of overall VA budget was redistributed under a simple capitated scheme, and some individual networks and facility types experienced changes in funding of over 30%. Models based on clinical data resulted in only minor differences from average-cost reimbursement. Substantial variation in practice style was observed across Veterans Integrated Service Networks (VISNs), which was significantly associated with funding shifts under capitation. Discussion: A simple capitated payment scheme would result in large changes in funding for some VISNs. Adjustments for case mix did not substantially affect patterns of redistribution. Patterns of redistribution appear to reflect large differences in practice style across VISNs. Although a capitated system will create incentives to reduce such variation, the effect of such shifts on patient well-being is unknown. Implications for Health Policies: Any capitated system will create incentives to provide a uniform standard of care. In our analyses, the capitation rate was based on the average cost per treated patient in each category; however rates could be set higher or lower as policy makers deem necessary. The standard of care associated with the average cost is not necessarily the ‘correct’ level of care. Implications for further research: Our analyses explore the implications of capitated systems for mental health patients in the absence of behavioral change. Further research is needed to determine how providers actually respond to the different incentives created by capitation and what impact these changes have on patient well-being. Copyright © 2000 John Wiley & Sons, Ltd.

Study Design Issues in Sepsis Trials

There have been over thirty large randomized controlled trials of novel anti-sepsis strategies that have failed to demonstrate clinical benefit. While some have argued this is because of a poor understanding of the underlying biology and pathophysiology of sepsis, it is also possible that there are problems with the eurrent design and implementation of sepsis trials, In particular, there are potential problems with sample size, patient selection, and choice of end-points. Although large, most sepsis trials are markedly underpowered in comparison to similar studies in other fields such as cardiology. Given the advances in the care of septic patients, the numerous processes that can influence outcome, and variation in practice style, it is likely that many new therapies will have only small, albeit important, clinical effects, To capture such effects, we must consider much larger trials. Patient selection is problematic because sepsis is both a vague term, hampering precise selection criteria, and covers a broad mix of patients, of whom many have a wide range of underlying risk factors, other than sepsis, for ad verse outcome, To lessen the problems of imprecise definition and heterogenons patient populations, we must consider either developing more accurate diagnostic criteria or studying more select populations, such as those with specific infections, The current end-point is 28-day mortality, This end-point may be too early, failing to capture the true impact of sepsis on subsequent outcome, and too insensitive, failing to capture important effects on non-mortal outcomes of potential therapies. Alternative end-points include long-term quality-adjusted survival or the development of proxies for longer-term ontcomes. Although organ failure scores may be proxies for long-term outcome, definitive evidence is lacking, In summary, while efforts continue in the pre-clinical arena, optimal investigation of novel anti-sepsis therapies requires reassessment of current trial design, including ex ploration of more homogeneous patient populations, devel opment of more sensitive or restrictive diagnostic criteria, and consideration of new end-points.

Capitated payments for mental health patients: a comparison of potential approaches in a public sector population.

BACKGROUND: Both private and public health care systems have embraced capitated reimbursement as a method of controlling costs. AIMS OF THE STUDY: This study explores the financial implications of using reimbursement models based on clinically based patient classification schemes to distribute funds for the treatment of mental health patients in the Department of Veterans Affairs (VA). METHODS: We identified 53700 veterans treated in VA specialty mental health outpatient clinics during the first 2 weeks of fiscal year (FY) 1991 for whom relevant clinical data were available. We calculated total utilization and costs for this sample during the remainder of FY 1991 using VA administrative databases and simulated hypothetical distributions of funds based on seven alternative capitation models. The resulting distributions of funds across service networks and facility types were compared to actual expenditures. RESULTS: Approximately 8% of overall VA budget was redistributed under a simple capitated scheme, and some individual networks and facility types experienced changes in funding of over 30%. Models based on clinical data resulted in only minor differences from average-cost reimbursement. Substantial variation in practice style was observed across Veterans Integrated Service Networks (VISNs), which was significantly associated with funding shifts under capitation. DISCUSSION: A simple capitated payment scheme would result in large changes in funding for some VISNs. Adjustments for case mix did not substantially affect patterns of redistribution. Patterns of redistribution appear to reflect large differences in practice style across VISNs. Although a capitated system will create incentives to reduce such variation, the effect of such shifts on patient well-being is unknown. IMPLICATIONS FOR HEALTH POLICIES: Any capitated system will create incentives to provide a uniform standard of care. In our analyses, the capitation rate was based on the average cost per treated patient in each category; however rates could be set higher or lower as policy makers deem necessary. The standard of care associated with the average cost is not necessarily the "correct" level of care. IMPLICATIONS FOR FURTHER RESEARCH: Our analyses explore the implications of capitated systems for mental health patients in the absence of behavioral change. Further research is needed to determine how providers actually respond to the different incentives created by capitation and what impact these changes have on patient well-being. lems.

Medical practice variations: changing the theoretical approach

Variations in medical practice are well documented, but there has been less progress in explaining these variations. This paper discusses the existing theories and hypotheses and concludes that a change in theoretical approach is required, to one that more directly highlights the social context influencing the behaviour of doctors in their daily practice. An initial alternative model for explaining variation in practice style is presented. The paper illustrates how (combinations of) important structural factors, such as the availability of hospital resources, the way the doctor is reimbursed, the availability of patients, professional uncertainty, and the way the hospital is financed, lead to hypotheses about when different local standards of medical care emerge. It is concluded that theoretical progress in research on variations in medical practice is possible and that empirical research needs to be driven by hypotheses that emphasize the role of social contexts in the doctor's decision behaviour. Some suggestions for future lines of research are outlined.

Managed care in benign gynecology

Although managed care has been viewed by many as an intrusion into medical practice, the stated goals of its proponents are to improve practice outcomes in a cost-effective manner and change the focus of health care to disease prevention and rational clinical resource utilization. Because health care costs have risen consistently in excess of normal inflation, pressure has mounted to move away from traditional fee-for-service reimbursement and indemnity insurance to capitated payment and 'third party' managed care. Studies have shown that the number of providers of gynecologic care is currently in excess of demand based on a managed-care model. Success in managed care will therefore require an understanding of the new economics of health care and a commitment to the appropriate use of medical and surgical interventions. Research should focus on identifying and reducing the unintended and wasteful variation in practice style that currently exists for benign gynecology and all of health care. Clinical guidelines that are derived from actual measured outcomes and adjusted for severity of illness and co-morbid conditions should replace 'clinical opinion' and allow gynecologists to efficiently manage patients with a minimum of third-party interference.

Improving Performance with Clinical Decision Support

CADU/CIS (Clinical and Administrative Decision-support Utility and Clinical Information System) is a clinical decision-support workstation that allows large volumes of clinical information systems data to be analyzed in a timely and user-friendly fashion. CARE PROCESS MEASUREMENT: For any given disease, subgroups of patients are identified, and automated, customized "clinical pathways" are generated. For each subgroup, the best practice norms for use of test and therapies are identified. Practice style variations are then compared to outcomes to focus inquiry on decisions that significantly affect outcomes. INTESTINAL OBSTRUCTION: Graduate Health Systems, a multisite integrated provider in the Philadelphia area, has used CADU/CIS to improve quality problems, reduce treatment-intensity variations, and improve clinical participation in care process evaluation and decision making. A task force selected intestinal obstruction without hernia as its first study because of the related high-volume and high-morbidity complications. Use of a ten-step method for clinical performance improvement showed that the intravenous administration of unnecessary fluids to 104 patients with intestinal obstruction induced congestive heart failure (CHF) in 5 patients. Task force members and other practicing physicians are now developing guidelines and other interventions aimed at fluid use. Indeed, the task force used CADU/CIS to identify an additional 250 patients in one year whose conditions were complicated by CHF. A clinical decision support tool can be instrumental in detecting problems with important clinical and economic implications, identifying their important underlying causes, tracking the associated tests and therapies, and monitoring interventions.

Further Issues in Small Area Variations Analysis

In this article, I examine Wennberg's "practice style" hypothesis and the literature on variations among small areas. According to Wennberg, geographic variations in rates of per capita use for many clinical procedures arise mainly from differences over what constitutes appropriate care. I show, however, that the role of practice style in explaining variations among areas has not been clearly demonstrated. I also argue that the practice style hypothesis can neither be established nor refuted by the methods traditionally used to study small areas and, moreover, that inferences about practice style variations cannot be drawn from differences among areas in their rates of use. I thus conclude that more research at the micro level in the practice patterns of the individual physician is needed before major health care initiatives based on small area methodology are undertaken.

Physician practice style variations

This article studies the variation in physician practice style among geographic regions and across time. A physician practice profile is defined and a simple model for profile variation is developed. Ratios are calculated for the components of the profile—ambulatory visit rate, hospitalization rate and length of hospitalization—and studied in terms of adaptation to resource constraint and nonspecific style. The methods are applied to hospital use in the Census Metropolitan Areas of Canada.