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That there is considerable variation in the everyday clinical behavior of physicians (both diagnosis and clinical management) has been extensively documented over several decades.1 The focus of research to explain this variability has shifted over time-from patient attributes, to provider characteristics, to organizational influences. We find it useful to conceive of three evolving generations of work: First generation studies showed how clinical decisions are influenced by who the patient is (e.g. their gender, race/ethnicity, age and socio-economic status); Second generation studies shifted to characteristics of the provider (e.g., medical specialty, age/clinical experience and gender, among other factors); Third generation work is now examining organizational and health system differences (e.g., type of ownership, practice size, availability of electronic support systems, practice culture and reimbursement schemes). Differences between physicians practicing in different national healthcare systems are an emerging area of work.2 Together, these studies suggest that physician decision making is influenced as much by who the patient is, who the physician is, and the type of setting in which care is received, as it is by what the patient actually has (the signs and symptoms of disease). Most of the work to date has examined these different influences on clinical decision making in isolation (i.e., they are de-contextualized), without regard to the likely simultaneous contribution of factors representing other generations of work. An effect that is attributed to, say, patient attributes (like age and race/ethnicity) may overlook other competing influences (e.g., physician characteristics and features of the practice setting). This is akin to a recognized problem in epidemiology whereby the influence of a solitary risk factor is highlighted (e.g., nutrition) with little regard for additional and possibly even more influential factors (e.g. exercise and smoking). The concept of relative contributions gives emphasis to the simultaneous influence of a range of variables, or levels of influence, to clinical decision making. From a statistical perspective we are essentially interested in the proportion of the total variance in physician behavior explained by all three generations of work combined, and then how much is explained by each generation separately, and within each generation, the explanatory contribution of separate factors. We hypothesize that patient attributes, physician characteristics and features of the practice setting contribute separately and equally to the diagnosis and management of diabetes. The goal of this paper is to estimate the relative contribution of patient attributes, physician characteristics and organizational influences to: a) the appropriate diagnosis for a “patient” presenting with signs and symptoms strongly suggesting diabetes; and b) the appropriate management of an already diagnosed case of diabetes (with an emerging foot neuropathy). This work has both clinical and health policy implications—by identifying factors which influence the quality of care provided by primary care physicians (who continue to manage the vast majority of diabetes in the community) and by identifying specific areas where interventions designed to improve the quality of diabetes care are likely to be more effective. |
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