July 15, 2019

Doctors aren't any better than the rest of us at avoiding low-value care, study finds

Daily Briefing

    Doctors aren't much better than other patients when it comes to receiving recommended high-value care and foregoing unwarranted low-value services, according to a new working paper from the National Bureau of Economic Research.

    Cheat sheets: Evidence-based medicine 101

    Details on the paper

    For the paper, which is undergoing peer review, the researchers set out to test the "belief that the key barrier to achieving high-quality and low-cost health care is the deficiency of information and medical knowledge among patients." To do so, the researchers compared utilization of low-value and high-value services among an informed group patients—physician patients—with the utilization of those services among a less informed group of patients—a group of patients who are not physicians.

    The low-value services that the researchers looked at include caesarian sections and chest X-rays before low-risk surgeries, such as cataract removal. The high-value services that the researchers looked at include statin use among patients with cardiac risk, comprehensive pre-diabetes care, and childhood vaccinations.

    Key findings

    The researchers found that physician patients "do only slightly better in adhering to both low- and high-value care guidelines than non-physicians–but not by much and not always."

    When it came to low-value services, the researchers found that the predicted rate of C-sections among pregnant female physicians was about 1 percentage point lower than the rate among the non-physician group but still higher than the 10% to 15% World Health Organization (WHO) considers appropriate.

    The authors wrote, "These results therefore suggest that, at most, we may only observe a minor improvement in outcomes—defined here as greater adherence to the established ideal—when providing patients with substantially greater sources of information."

    Physician patients were also less likely than non-physician patients to receive unnecessary pre-surgical diagnostic testing but the researchers said testing among physician patients was still happening too often.

    When it came to high-value services, the researchers found hardly any difference in utilization between physicians and non-physicians when it came to post-cardiac care or vaccinations for diptheria/tetanus/pertussis and hepatitis. Physician patients with diabetes were no more likely than non-physician patients with diabetes to get medically recommended tests and exams, the researchers found.

    Discussion

    Study co-author Michael Frakes of Duke University said, "[Physician patients] went through internships, residencies, fellowships. They're super informed." He continued, "And even then, they're not doing that much better."

    Looking at the findings, Gruber said, "The right answer for our system is not to tell patients they can't have service X, but to say service X isn't cost-effective—if you want it you have to pay for it." He added, "That's controversial and hard, but the lesson from this paper is that we should bring expert analysis into cost sharing, rather than relying on consumers to figure it out."

    The study wasn't designed to explain why physicians don't receive high-value services or why they opt to receive low-value ones despite evidence that they're not needed. However, the authors put forward theories that might explain the findings. For instance, Frakes said that like patients, physicians opt for low-value services despite evidence that they're not necessary out of deference to the authority of a physician.

    Meanwhile, The Atlantic reports that, similar to patients, physicians might forgo high-value services because of constraints or financial considerations (Frakes et al., National Bureau of Economic Research working paper, July 2019; Frakes et al., National Bureau of Economic Research abstract, July 2019; Hiltzik, Los Angeles Times, 7/8; Khazan, The Atlantic, 7/9).

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