physician practice style and barriers to referral: los angeles women’s health study
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Physician Practice Style Physician Practice Style and Barriers to Referral: and Barriers to Referral:
Los Angeles Women’s Los Angeles Women’s Health StudyHealth StudyDanielle Rose Ash, PhDDanielle Rose Ash, PhD
VA HSR&D/Greater Los Angeles Care VA HSR&D/Greater Los Angeles Care SystemSystem
Co-Authors: Diana Tisnado, PhD, Jennifer Co-Authors: Diana Tisnado, PhD, Jennifer Malin, MD, PhD, May Lin Tao, MD, John Adams, Malin, MD, PhD, May Lin Tao, MD, John Adams,
PhD,PhD,Patricia Ganz, MD and Katherine Kahn, MDPatricia Ganz, MD and Katherine Kahn, MD
Funding from CA Breast Cancer Research Funding from CA Breast Cancer Research Program, Program,
National Cancer Institute and VA-HSR&DNational Cancer Institute and VA-HSR&D
21 Starfield et al 2005 2 Pham et al 2007
BackgroundBackground
Improved medical technology Improved medical technology requires greater more specialists requires greater more specialists involved in care, particularly among involved in care, particularly among elderlyelderly11
Patients seeing numerous providers Patients seeing numerous providers in numerous settingsin numerous settings22
Breast cancer care involves multiple Breast cancer care involves multiple physiciansphysicians
3Smith, Allwright, O'Dowd, 2008
Shared CareShared Care
“…“…the planned delivery of care for the planned delivery of care for patients with a chronic condition, patients with a chronic condition, informed by an enhanced information informed by an enhanced information exchange over and above routine exchange over and above routine discharge and referral letters”discharge and referral letters”
4
Specific AimsSpecific Aims
Examine physician report of Examine physician report of co-co-managing managing carecare v. other styles v. other styles
Examine Examine variations variations in in physician physician practice stylepractice style
5
Los Angeles Women’s Los Angeles Women’s Health Study Data Health Study Data
CollectionCollectionPopulation-based study of women >50 identified as newly
diagnosed with breast cancer by RCA in Los Angeles County, 2000
1224 women completed detailed CATI (64% response rate)
Women identified 477 physicians providers who delivered, recommended or discussed possible use
of treatments
Analytic cohort: 111 medical oncologists, 66 radiation oncologists
and 171 surgeons in 298 offices (N=348)
Final response rate was 76%
6
A 65-year-old woman with well-A 65-year-old woman with well-controlled diabetes, has been controlled diabetes, has been newly diagnosed newly diagnosed with breast with breast
cancercancer Domain 1: Approach to the PatientDomain 1: Approach to the Patient
Establish goals for cancer treatment and Establish goals for cancer treatment and prognosis prognosis
Domain 2: Decision-making Domain 2: Decision-making Type of breast surgery Type of breast surgery
Domain 3: Treatment of Signs, Symptoms Domain 3: Treatment of Signs, Symptoms and Co-morbiditiesand Co-morbidities Managing diabetes Managing diabetes
7
Physician Practice StylePhysician Practice Style I provide this care myself without I provide this care myself without
much input from another clinicianmuch input from another clinician I co-manage or decide jointly about I co-manage or decide jointly about
this care with another clinicianthis care with another clinician I refer patients to another clinician I refer patients to another clinician
for this aspect of carefor this aspect of care I am not involved in this aspect of I am not involved in this aspect of
carecare
8
Predicting Physician Predicting Physician Practice StylePractice Style
PHYSICIAN PRACTICE STYLE
Independent
Co-manage
Refer to other MDs
Do not handle care
PHYSICIAN CHARACTERISTICS
- Age, Gender and Specialty
FINANCIAL CHARACTERISTICS
- Reimbursement, Financial Incentives to Services
PRACTICE CHARACTERISTICS
-Practice Setting and Size
-# New Cancer Patients/Month
-Tumor Board Participation
- Barriers to Referrals: Provider Network Restrictions
9
Analytic MethodsAnalytic Methods
Multivariate logistic regressionMultivariate logistic regression Present predicted probabilitiesPresent predicted probabilities Weighted for provider non-responseWeighted for provider non-response Adjusted for clustering at the Adjusted for clustering at the
physician office levelphysician office level Bonferroni adjustment for multiple Bonferroni adjustment for multiple
comparisonscomparisons Tested for interactionsTested for interactions
10
40% of Physicians Report Co-40% of Physicians Report Co-Managing the Establishment of Managing the Establishment of
Cancer Treatment Goals Cancer Treatment Goals
1% 0% 3%
23%
50%
23%
42%
38%
47%
34%
12%27%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Med Onc Rad Onc Surgeon
IndependentI co-manageI referI do not handle
p<0.001 for specialty
11
Co-management by Provider Co-management by Provider Network Restrictions: Network Restrictions:
Approach to the PatientApproach to the Patient
8%2%
75%
30%
41%
11%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Med Onc Rad Onc Surgeon
No Restrictions Restriction
p<0.01 for provider network restrictions, adjusting for physician, financial and practice setting characteristics
12
Physician Practice Style in Physician Practice Style in Management of DiabetesManagement of Diabetes
1% 8% 9%
43%
91%
66%
42%
1%
19%14%
0% 6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Med Onc Rad Onc Surgeon
IndependentI co-manageI referI do not handle
p<0.001 for specialty
13
Co-management by Provider Co-management by Provider Network Restrictions: Network Restrictions: Treatment of DiabetesTreatment of Diabetes
87%
73%
1% 1%9% 6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Med Onc Rad Onc Surgeon
No Restrictions Restriction
Adjusting for physician, financial and practice setting characteristics
14
ConclusionsConclusions
Rates of co-managementRates of co-management Highest rates for approach to patientsHighest rates for approach to patients Lower rates for decision-making and Lower rates for decision-making and
treatment of signs, symptoms and co-treatment of signs, symptoms and co-morbiditiesmorbidities
Variations in practice style by specialty Variations in practice style by specialty and practice setting characteristicsand practice setting characteristics
Provider network restrictions were Provider network restrictions were associated with less co-managementassociated with less co-management
15
LimitationsLimitations
GeneralizabilityGeneralizability 21% of physicians reported network 21% of physicians reported network
restrictions to high-quality referrals in restrictions to high-quality referrals in Los Angeles CountyLos Angeles County
National data show provider network National data show provider network restrictions are prevalent in HMOs and restrictions are prevalent in HMOs and non-HMO settingsnon-HMO settings
Clinical scenarios Clinical scenarios Social desirability biasSocial desirability bias
16
Policy ImplicationsPolicy Implications
Co-management may address Co-management may address fragmentation in the health care systemfragmentation in the health care system
Co-management rates across domains Co-management rates across domains are less than 50%are less than 50%
Next steps need to analyze:Next steps need to analyze: Does co-managed care improve process of Does co-managed care improve process of
care and patient outcomes?care and patient outcomes? Cost trade-offs associated with co-managed Cost trade-offs associated with co-managed
carecare
Thank you!Thank you!
18
LA Women’s Health Study – LA Women’s Health Study – Data CollectionData Collection
Rapid Case Ascertainment identified women 50 and older with incident breast cancer in LA (excluding Asian women 55-70 years) N=2,745
Patients with incident breast cancer 50 years and older located N= 2,306
Complete LA Women’s Health Study baseline survey. Response rate 55%, N=1,269
19
Final response rate was 76%, 67% for medical oncologists, 89% for radiation oncologists and 80% for surgeons.
Analytic cohort defined as: 111 medical oncologists, 66 radiation oncologists and 171 surgeons in 298 offices (N=348)
477 unique medical oncologists, radiation oncologists and general or breast surgeons identified & targeted for provider survey
Women identified physicians (n=747) as fulfilling roles associated with medical oncologists (n=251), radiation
oncologists (n=122) or surgeons (n=374)
20Adjusting for physician, financial and practice setting characteristics
Practice Style by Provider Practice Style by Provider Network Restrictions: Network Restrictions:
Management of Diabetes Management of Diabetes
87%
1%9%
73%
1%6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Med Onc Rad Onc Surgeon
6% 5%3%
28%
23%
14%
0%
5%
10%
15%
20%
25%
30%
Med Onc Rad Onc Surgeon
Co-managed Care Independent Practice Style
p<0.01 for provider network restrictions for independent practice style
21
Provider Network Provider Network RestrictionsRestrictions
Associated with less co-managementAssociated with less co-management Approach to the patientApproach to the patient Decision-making: radiation therapyDecision-making: radiation therapy Treatment: Prescribing opiates for painTreatment: Prescribing opiates for pain Never associated with more co-managementNever associated with more co-management
Associated with more independent Associated with more independent practice stylepractice style Decision-making: radiation therapyDecision-making: radiation therapy Treatment: arm symptoms, diabetesTreatment: arm symptoms, diabetes
22Adjusting for physician, financial and practice setting characteristics
Practice Style by Provider Practice Style by Provider Network Restrictions: Network Restrictions: Approach to PatientApproach to Patient
8%
75%
41%
2%
30%
11%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Med Onc Rad Onc Surgeon
77%
18%
5%
90%
40%
16%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Med Onc Rad Onc Surgeon
CoManagement Style
Independent Practice Style
p<0.01 for provider network restrictions
23
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