physician practice style and barriers to referral: los angeles women’s health study

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%


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%


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%


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

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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

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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%


6% 5%3%

28%

23%

14%

0%

5%

10%

15%

20%

25%

30%


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%


77%

18%

5%

90%

40%

16%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


CoManagement Style

Independent Practice Style

p<0.01 for provider network restrictions

physician practice style and barriers to referral: los angeles women’s health study

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