Variable practice patterns among physicians is said to be a cause of excessive spending. One method by which that variation is being tamped down is use of process of care measures that try to enforce “evidence-based” medical treatment regimens. Physicians are measured and in some cases penalized or rewarded for behavior. One danger of this approach is a one-size-fits-all approach that may not be consistent with patient needs. Another is that scientific evidence about best treatments has a habit of shifting over time. Research in the Journal of Health Economics examines what the implications of variable practice patterns in treating heart attacks may be. (JHE Study) The authors divided physicians according to the “aggressiveness” of their approach to treating patients who presented with symptoms of acute myocardial infarction and tried to measure the extent to which they varied treatment by patient characteristics. The used data from Florida emergency rooms between 1992 and 2014 and examined the characteristics of patients arriving at the ER with AMI symptoms and the subsequent treatment approach.
The “aggressive” physicians were those who tended to quickly use more interventional procedures and who tended to do so across all patients. The relative standard of care was based on what seemed to be the actual practice in teaching hospitals. There was substantial variation among doctors in how much they appeared to take patient characteristics into account. For example, some doctors were much less likely to use intensive treatment on the oldest and sickest patients. The analysis indicated that physicians who treat all patients very aggressively, without regard to characteristics, have high spending but also have the best outcomes. Those doctors who appeared to tailor treatment by patient factors had lower spending but worse outcomes for patients who were older and sicker. The doctors who seemed to be most responsive to patient characteristics tend to have more practice experience and to be female. Those who were more aggressive in treatment patterns were younger and more likely to come from top 20 medical schools. The authors suggest that their results indicate that doctors who try to decide which patients will benefit from more aggressive treatment may be creating less than optimal outcomes for the patients they don’t treat aggressively. It is worth noting that this study is limited to cardiologists and that the “quality” outcomes considered are not necessarily representative of real, longer term outcomes, including patient quality of life.