It is recognized that medical practice varies widely across the United States. Extensive work using Medicare claims has shown many-fold variations in the use of specific services and procedures between different, even neighboring, communities. Underlying the wide variation is a poorly understood characteristic called clinical practice intensity - the tendency of individual providers to order tests, referrals and treatments. Practice intensity is important not only because it is a powerful determinant of health care costs, but also of health care outcomes. The VA in particular needs to understand practice intensity. Because VA providers experience different pressures than their counterparts in the private sector, there is reason to believe they may behave differently.
1. To describe practicing primary care physicians experience of providing health care services in the U.S.
2. To characterize practice intensity of U.S. primary care physicians' and the forces that influence it.
3. To compare practice intensity and beliefs and perceptions about health care delivery between VA physicians and their private sector counterparts.
STUDY DESIGN: National mail survey of VA primary care physicians and non-VA primary care physicians.
SURVEY INSTRUMENT: The survey included clinical management questions in the form of clinical vignettes as well as questions about physicians' perceptions of medical practice.
SURVEY DEVELOPMENT: The survey was developed with the collaboration of a contracted survey research firm, Harris Interactive. Two physician focus groups were held to better understand how primary care physicians think about the practice of medicine and the factors that influence their decision making. The survey draft was developed through an iterative process of revision. Draft and near final survey versions were evaluated through a dozen cognitive interviews with practicing primary care physicians.
SAMPLE: Primary care physicians who practice at least 20 hours per week will be eligible to participate. Two groups of physicians were sampled: non-VA primary care physicians (internal medicine, family medicine, general practice) through the AMA Masterfile; and VA primary care physicians identified through the national Primary Care Management Module database.
ADMINISTRATION: The survey was administered by mail by Harris Interactive, an international survey research firm. Private sector participants received a financial incentive as an honorarium. We exceeded our projected response rate for non-VA physicians but not VA physicians.
ANALYSIS: We have performed simple descriptive statistics and analyses comparing VA with private sector physicians. Secondary analyses will control for characteristics of physicians, patients, and practice environment.
The survey instrument was fielded in a first mailing in mid-June 2009; VA physicians received three additional mailings over a 6 month period, non-VA providers received 2 additional mailings. Response rates are as follows: non-VA physicians 70%, VA physicians 40%.
Major findings to date include the following:
Nearly half of primary care physicians in the U.S. believe their patients are receiving too much medical care; few say they are receiving too little.
For primary care physicians, factors encouraging aggressive practice style include malpractice concerns, clinical performance measures, and inadequate time to spend with patients. VA physicians are particularly sensitive to clinical performance measures as well as the hassle of communicating with a patient's other providers.
Most physicians perceive that diagnostic testing would be reduced in the absence of direct financial benefit derived by physicians from such testing. Although the majority of VA physicians stated that they did not order diagnostic test for financial gain, they still believed that fewer tests would be ordered if they did not generate revenue.
The overwhelming majority of primary care and VA physicians in the United States are interested in how they practice compared with others in their community, and how their community compares to others in the country.
Differences between VA and non-VA physicians were generally small; where they existed, VA physicians practiced somewhat less intensively than their private sector counterparts.
By identifying common clinical decisions for which evidence is lacking and there is high variability among physicians, our study provides important insight into the range of "resource-intensive gray areas" within VA and non-VA practice.
By benchmarking providers and facilities against VA and community practice norms, we invite discourse about and target interventions related to improved clinical decision-making in the absence of evidence.
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- Sirovich BE, Gottlieb DJ, Welch HG, Fisher ES. Regional variations in health care intensity and physician perceptions of quality of care. Annals of internal medicine. 2006 May 2; 144(9):641-9.