Provider practice style and patient health outcomes: The case of heart attacks

Abstract

When a patient arrives at the Emergency Room with acute myocardial infarction (AMI), the provider on duty must quickly decide how aggressively the patient should be treated. Using Florida data on all such patients from 1992 to 2014, we decompose practice style into two components: The provider's probability of conducting invasive procedures on the average patient (which we characterize as aggressiveness), and the responsiveness of the choice of procedure to the patient's characteristics. We show that within hospitals and years, patients with more aggressive providers have consistently higher costs and better outcomes. Since all patients benefit from higher utilization of invasive procedures, targeting procedure use to the most appropriate patients benefits these patients at the expense of the less appropriate patients. We also find that the most aggressive and responsive physicians are young, male, and trained in top 20 schools.

The value of process friction: The role of justification in reducing medical costs

“…For example, discussing the use of invasive cardiac procedures, Currie, MacLeod, and Van Parys (2016) explain that if "surgery becomes generally safer over time," and thus less costly to conduct, "then it may make sense to use aggressive procedures on more marginal patients over time." Prior research has found that physicians utilize procedures based on ease and safety of use.…”

“…There are two manners in which justification could decrease US use: physicians could be less "aggressive" in US use for all patients in general, or they could be more "responsive" to clinical need and reduce usage primarily for marginalprobability patients (Currie et al, 2016). Abdominal USs are the preferred modality for only certain medical conditions (please see Section 4 and Appendix B for more detail) (American College of Emergency Physicians, 2008).…”

“…Aggressiveness, or the willingness to perform more procedures (Currie et al, 2016), in choosing a treatment is more of a physician-specific preference (Currie et al, 2016), and there is no reason to believe that justification would change an individual physician's preference for a test. Aggressiveness, or the willingness to perform more procedures (Currie et al, 2016), in choosing a treatment is more of a physician-specific preference (Currie et al, 2016), and there is no reason to believe that justification would change an individual physician's preference for a test.…”

“…If a reduction in available processing time is a mechanism, then with less time available when justification is required, we expect physicians to only order tests that are the most clinically appropriate (Currie et al, 2016), which should reduce other "non-focal" (i.e., not USs) tests, including CTs and "consults" to other physicians. When USs are ordered and justification is required, there is less time available to order any and all other tests due to the increased ordering time.…”

“…Physician fixed effects are represented by the vector MD, to control for different physician skills, training, and practicing styles (Currie et al, 2016;Stiell et al, 1997). We control for any differences between the hospitals with an indicator variable, Genij, equal to 1 if patient i is seen at General, and 0 otherwise.…”