Many factors contribute to a patient’s health, including genetic makeup, lifestyle choices around factors like diet and exercise, environmental factors and the nature of the health care they receive. A new paper at the National Bureau of Economic Research explores the role that a physician’s management skills may play in a patient’s health. (NBER Paper) I have to say this seems like a tricky exercise, particularly when many patients see multiple doctors and many patients don’t follow physicians’ recommendations or orders. But the researchers plowed ahead and it is an important question; if we could in fact identify characteristics of health management styles that led to better outcomes, we could train physicians to adopt the best health management approach. They used a Danish registry to look at adherence with medication regimens, specifically lipid-lowering drugs, and examined effects on hospitalizations and costs for cardio-vascular disease. They adjusted for possible patient selection factors into particular physician groups and various patient characteristics. Describing management styles seems to be more art than science. Communication is obviously important, as is the ability to understand the arguments that will best motivate a patient to be compliant and to take better care of their health. Physicians in Denmark have a limited ability to turn away patients, so it is difficult for a doctor to influence what patients they see. The researchers were able to create somewhat of a natural study by analyzing adherence when a patient switched from one doctor to another, usually because of clinic closures or a patient moving. About 15% of the study population had such a switch during the study period. They found that patient adherence to a statin improved when they switched to a physician with greater health management skill and decreased when the opposite occurred. They also show that such patients also demonstrated a change in the opposite direction in rate of hospitalizations and spending, so that those who went to a more skilled doctor had fewer hospitalizations and spending, and vice versa.
But the sole basis for ascribing a level of health management skill to a physician in this study was medication adherence across the practice. That seems pretty limited and pretty uninformative as to what the doctor was actually doing that might increase adherence. Some factors they did look at, like gender, immigration status and age, suggest that older physicians have less health management skills, which seems counterintuitive, since older doctors should have more experience in figuring out how to influence patient behavior. I don’t buy the notion, expressed by the authors, that more recently trained physicians have learned better management skills. One very cautionary side finding is that physician clinical quality measure scores appear to in fact be largely due to patient selection issues, for example, patients who are more likely to be adherent tend to be more likely to track physician quality scores and go to doctors with higher scores. I assume the same is likely true in the US. More work needs to be done to uncover the exact patient characteristics that lead to these selection issues which may confound true quality of care delivered. If the most knowledgeable, skilled doctor only has patients who are completely disinclined to follow recommendations and comply with ordered treatment, that doctor’s quality scores are not going to look good. On the other hand, a mediocre physician who has a practice full of highly compliant, motivated patients will likely have good quality scores.