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Principal Investigator: John Ware, Jr., Ph.D., The New England Medical Center.
Grant Number: HS 06073.
Project Period: January 1988 to December 1991.
Differences in the effectiveness of medical and surgical procedures and drugs are not the only
factors behind variations in patient care. Where a physician practices, his or her training, and
interpersonal style, or bedside manner, also affect patient outcomes and health care
costs.
Variations in Physician Practices Contents (Summer 1994)
Introduction
Supported by AHCPR, this study expands on the work of the national Medical Outcomes Study
of more than 20,000 adults in Chicago, Boston, and Los Angeles, who received care from
primary care and specialty physicians for one or more chronic conditions: hypertension, coronary
heart disease, diabetes, and depression. Variations in physician practice style and patient
outcomes were examined in three systems of care: health maintenance organizations (HMOs),
multispecialty groups, and solo practices.
Practice style involved resource use such as inpatient and outpatient visits, referrals, tests
ordered, procedures done, and medications prescribed. Also included were interpersonal issues
such as the provider's manner with patients, counseling and communication skills, and the level
of patient participation in care and treatment decisions. An important focus was patients'
perceptions of their general health and well-being, their ability to function in everyday living, and
their satisfaction with treatment.
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Findings
Among the findings published to date are the following:
- Patients insured through fee-for-service insurance plans and treated by single-specialty
physicians in solo practice were hospitalized 40 percent more than were HMO patients.
- HMO patients had 8 percent fewer physician visits than did fee-for-service patients of
single-specialty doctors in solo practice; these patients also took 12 percent fewer prescription
drugs.
- Medical specialists prescribe more drugs and tests than do primary care physicians, and
specialists are more likely to hospitalize patients with the same illnesses and severity levels.
- HMO physicians order fewer tests than do physicians in solo practice and group practice;
they are also less likely to hospitalize their patients.
- Patients who rated their health as poor in the SF-36 questionnaire developed as part of the
study used 10 times more hospital care than those who rated their health as excellent.
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Dissemination
Results of this study have been published in the Journal of the American Medical
Association, Archives of Internal Medicine, Archives of General Psychiatry,
Journal of Gerontology, Psychiatric Medicine, Cancer, Quality of Life
Research, Medical Care, and at least 11 other professional journals and books.
Dissemination Summary: Variations in Physician Style and Outcomes of Care
| Presentations: | 39 |
| Professional Articles: | 30 |
| Health Industry Articles: | 2 |
| Editorials/Mentions: | 14 |
| Consumer Print: | 14 |
| Consumer Broadcast: | 0 |
| Total: | 99 |
Given the role of quality of care in health care reform proposals now before Congress, this
AHCPR-funded study has drawn the attention of the daily press. Newspapers such as the
Wall Street Journal, New York Times, and Chicago Tribune have written
about the study, particularly about its development of the SF-36 questionnaire. The questionnaire
asks patients to rate their quality of life in terms of physical functional ability, social functional
ability, role limitations due to physical problems, degree of bodily pain, mental health status, role
limitations due to emotional problems, vitality, and general health perceptions.
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Implications
Understanding key factors for better patient outcomes would allow those elements of care to be
emphasized in managed systems with cost constraints. How patients fare with aggressive (and
usually more expensive) treatment or conservative approaches is central to the debate. Practical
tools to monitor patient health, such as an easy-to-use questionnaire with reliable results, could
yield better feedback for providers or help predict health needs. Such tools are also needed to
assess new drugs and treatments, health care quality, and the health organizations that provide
care.
The significance of interpersonal aspects of care to health outcomes could shift part of the health
policy debate to the need for better training of practitioners in these areas. Interpersonal style has
been linked to noncompliance with medical regimens, disenrollments from group practices, and
doctor-shopping.
This study also draws attention to the mix of physicians providing health care and how they are
organized—in HMOs, multispecialty groups, and solo practices. It may fuel concerns over a lack
of primary care doctors and a surplus of specialists, especially if the United States moves toward
a system of managed care networks in which generalists serve as gatekeepers in making referrals
to specialists. An important question for further analysis will be whether reduced use of health
services by HMOs affects the health outcomes of chronically ill patients.
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Bibliography
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