Variation in the Tendency of Primary Care Physicians to Intervene

Sirovich, Brenda E.; Gottlieb, Daniel J.; Welch, H. Gilbert; Fisher, Elliott S.

doi:10.1001/archinte.165.19.2252

Cited by 55 publications

(39 citation statements)

References 22 publications

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“…Similar to other areas of clinical practice (25,26), some evidence suggests that system-level factors may be important in shaping treatment decisions and dialysis initiation practices for patients with ESRD (27,28). However, to our knowledge, no prior studies have rigorously compared eGFR at initiation across health systems with differing reimbursement structures within the United States.…”

Section: Introductionmentioning

confidence: 90%

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs

O’Hare

Batten

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives The secular trend toward dialysis initiation at progressively higher levels of eGFR is not well understood. This study compared temporal trends in eGFR at dialysis initiation within versus outside the Department of Veterans Affairs (VA)-the largest non-fee-for-service health system in the United States.Design, setting, participants, & measurements The study used linked data from the US Renal Data System, VA, and Medicare to compare temporal trends in eGFR at dialysis initiation between 2000 and 2009 (n=971,543). Veterans who initiated dialysis within the VA were compared with three groups who initiated dialysis outside the VA: (1) veterans whose dialysis was paid for by the VA, (2) veterans whose dialysis was not paid for by the VA, and (3) nonveterans. Logistic regression was used to estimate average predicted probabilities of dialysis initiation at an eGFR$10 ml/min per 1.73 m 2 .Results The adjusted probability of starting dialysis at an eGFR$10 ml/min per 1.73 m 2 increased over time for all groups but was lower for veterans who started dialysis within the VA (0.31; 95% confidence interval [95% CI], 0.30 to 0.32) than for those starting outside the VA, including veterans whose dialysis was (0.36; 95% CI, 0.35 to 0.38) and was not (0.40; 95% CI, 0.40 to 0.40) paid for by the VA and nonveterans (0.39; 95% CI, 0.39 to 0.39). Differences in eGFR at initiation within versus outside the VA were most pronounced among older patients (P for interaction ,0.001) and those with a higher risk of 1-year mortality (P for interaction ,0.001).Conclusions Temporal trends in eGFR at dialysis initiation within the VA mirrored those in the wider United States dialysis population, but eGFR at initiation was consistently lowest among those who initiated within the VA. Differences in eGFR at initiation within versus outside the VA were especially pronounced in older patients and those with higher 1-year mortality risk.

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Section: Introductionmentioning

confidence: 90%

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs

O’Hare

Batten

et al. 2015

Clinical Journal of the American Society of Nephrology

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“…4,5 The specific specialist to whom a patient is referred can profoundly impact the clinical care trajectory for that patient because individual physicians differ in their approaches to care, including the use of high-cost services and quality of care. [5][6][7][8][9] In addition, future policy interventions to control cost growth will likely attempt to modify referral practices by either trying to prevent inappropriate referrals or steering providers to refer to colleagues who utilize fewer services. 10 In this context, understanding which factors motivate physicians to refer to particular colleagues could be crucial to the success of such interventions.…”

Section: Introductionmentioning

confidence: 99%

Reasons for Choice of Referral Physician Among Primary Care and Specialist Physicians

et al. 2011

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BACKGROUND: Specialty referral patterns can affect health care costs as well as clinical outcomes. For a given clinical problem, referring physicians usually have a choice of several physicians to whom they can refer. Once the decision to refer is made, the choice of individual physician may have important downstream effects. OBJECTIVE: To examine the reasons why primary care and specialist physicians choose certain specific colleagues to refer to and how those reasons differ by specialty. DESIGN: Cross-sectional Web-based survey supplemented with analysis of administrative claims data. PARTICIPANTS: A total of 616 physicians in office-based patient care specialties who were members of an academic physicians' organization and treated Medicare patients in 2006. MAIN MEASURES: A total of 386 respondents (63% response rate) were presented with a "roster" of other physicians' names with whom we predicted they had a relationship based on sharing Medicare patients. Among physicians in their "professional network" (consisting of any listed physician with whom respondents acknowledged a professional relationship), respondents reported if they referred to those physicians, and if so, provided up to two reasons why they referred to that particular colleague. Using logistic regression, we examined the likelihood that different specialists would endorse specific reasons for referring to chosen colleagues. KEY RESULTS: Primary care physicians (PCPs) initiated referrals to 66% of their "professional network" colleagues, while medical and surgical specialists initiated referrals to 49% and 52%, respectively (p<0.001 for both versus PCPs). After adjustment, medical specialists were less likely than PCPs to cite ease of communication with colleagues (RR=0.69, 95% CI=0.49-0.91), and medical and surgical specialists were less likely than PCPs to cite "shares my medical record system" as a reason to refer (medical specialist RR=0.13, 95% CI 0.03-0.40, surgical specialist RR=0.26, 95% CI=0.05-0.78). CONCLUSIONS: Specialists frequently initiate referrals, bypassing PCPs. In choosing specific physicians to refer to, PCPs are more often concerned with between-physician communication and patient access. Modifying referral practices among doctors may need to account for such patterns of behavior.KEY WORDS: health services research; physician referral; reasons for referral; primary care.

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“…[7][8][9][10] Additionally, studies show that for discretionary care, physicians within regions demonstrate similar preferences about intensity of services. 11,12 Nevertheless, patient sharing represents a plausible mechanism by which care coordination occurs, and the association with lower costs found using both Pollack's and Landon's approaches is encouraging, 3,5 although we should be cautious about the conclusions we draw from this early work. First, more information is needed on how care density is related to other potential confounding measures, such as geography (rural vs. urban settings) and number of total visits.…”

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confidence: 96%

A Measure of Care Coordination?

Bynum

Ross

2012

J GEN INTERN MED

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Variation in the Tendency of Primary Care Physicians to Intervene

Abstract: Varying rates of health care spending across the United States reflect the underlying tendency of local physicians to recommend interventions for their patients.

Cited by 55 publications

References 22 publications

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs

Reasons for Choice of Referral Physician Among Primary Care and Specialist Physicians

A Measure of Care Coordination?

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