Diagnostic Certainty as a Source of Medical Practice Variation in Coronary Heart Disease: Results from a Cross-National Experiment of Clinical Decision Making

Abstract

We examined physician diagnostic certainty as one reason for cross-national medical practice variation. Data are from a factorial experiment conducted in the United States, the United Kingdom, and Germany, estimating 384 generalist physicians’ diagnostic and treatment decisions for videotaped vignettes of actor patients depicting a presentation consistent with coronary heart disease (CHD). Despite identical vignette presentations, we observed significant differences across health care systems, with US physicians being the most certain and German physicians the least certain (p < .0001). Physicians were least certain of a CHD diagnoses when patients were younger and female (p < .0086), and there was additional variation by health care system (as represented by country) depending on patient age (p < .0100) and race (p < .0021). Certainty was positively correlated with several clinical actions, including test ordering, prescriptions, referrals to specialists, and time to follow-up.

Physician Cognitive Processing as a Source of Diagnostic and Treatment Disparities in Coronary Heart Disease

“…Classic work in medical decision making that suggests physicians must cross specific test- and treatment-certainty thresholds before taking clinical action for a patient (Pauker and Kassirer 1980), and recent empirical research on CHD corroborates the notion that certainty is more important than simply identifying a diagnosis (Lutfey et al 2008; Lutfey et al Forthcoming-a). Therefore, the presence of a CHD diagnosis within a full differential diagnosis is necessary but not sufficient to trigger clinical actions and needs to be understood in the context of these multiple factors.…”

Preventing and Experiencing Ischemic Heart Disease as a Woman: State of the Science

“…307–315 Physician uncertainty for CVD diagnosis has been shown to vary by patient sex and influence clinical decisions. 220,222,316 Indirect evidence also indicates that healthcare clinicians’ interpretation of symptoms are influenced by patient demographics, including sex/gender. 317–319 For example, physicians are more likely to interpret a man’s symptoms as organic and a woman’s as psychosocial.…”

Implicit Gender Bias and the Use of Cardiovascular Tests Among Cardiologists

“…Our participants estimated the likelihood of obstructive CAD in hypothetical male and female patients similarly but felt less certain of these estimates for the female patient. Other studies have similarly shown that physician certainty of cardiac diagnoses varied by patient gender and influenced clinical decisions 58, 59. Consequently, efforts to reduce gender disparities in management may need to focus on increasing physician certainty of evaluating suspected CAD in female patients.…”