An Additional Cause of Health Care

Disparities: The Variable

Clinical Decisions of
Primary Care Doctors
KAREN HUACASI
Background
PRIMARY QUESTION OF INTEREST

• What is the influence of patient, provider and

organizational factors on the variability of
diagnosis and management of a major chronic
disease – diabetes?
MAIN OBJECTIVE

• Describe variability in doctor’s decision making

in the initial diagnosis of diabetes and the
contribution of patient, doctor and
organizational factors to any variability
Background
IMPORTANT BECAUSE
• Diabetes mellitus is the “the health hazard
of the 21st century” according to WHO
• Understanding what influences the
variability in diagnosis and management
of diabetes can help improve quality and
reduce disparities.

• Finding out exactly where these variations

begin (patient, provider, or organization)
can help guide educational, clinical and
policy level interventions
Methods
BALANCED FACTORIAL ANOVA
DESIGN Factors Level 1 Level 2 Level 3 Observations

• Research question calls for assessing the effects of

four independent variables on the initial diagnosis Patient Gender Female Male 96 + 96 = 192
of diabetes
• 2 x 2 x 2 x 3 = 233 design Patient Age 35 65 96 + 96 = 192
• 24 experimental conditions  24 versions of
Patient socio- Janitor Lawyer 96 + 96 = 192
each scenario economic status
• Dependent Variable
Patient Black Hispanic White 64 + 64 + 64 =
• Diagnostic accuracy and certainty race/ethnicity 192

• Permits estimation of the main effects of each factor

and interactions between factors
• ANOVA statistical test
Methods
PROCEDURE
• 192 primary care doctors watched a video of a ‘patient’ with
undiagnosed diabetes presenting clear indicators of T2DM
• 24 different versions of the video varied by patient age,
race/ethnicity, gender, and socioeconomic status (SES)
while presentation of symptoms stayed exactly the same
• Doctors were asked to
• Identify the “most likely condition”
• Rate level of certainty from 0-100 for each diagnosis
• Discuss how they’d confirm diagnosis and treat patient
• Experiment was replicated

DESIGN OF STUDY CLEARLY TIES TO MAIN

OBJECTIVE
Methods
SAMPLING PROCEDURE DATA SOURCES
• Purposive sample selected from American • Primary data source
Medical Association list of doctors practicing • Differential diagnostic possibility
in New Jersey, New York, and Pennsylvania
• Open ended responses were recorded during
• Eligible doctors the interview

• Stratified: gender and clinical experience

• Purposively recruited until each cell was • Level of certainty for each diagnostic possibility
complete • Recorded as a number 0-100

• Sample of 192 physicians

• Confirmation and treatment of diagnosis
• Structured interview questions
 Results
Summary Table: Diagnoses and certainty of diagnosis for patients
presenting with symptoms suggestive of diabetes

Patient gender Patient age Patient SES Patient race/ethnicity

Female Male 35 65 Janitor Lawyer Black Hispanic White
P- P- P- P-
n= 96 n=96 value n=96 n=96 value n=96 n=96 value n= 64 n=64 n=64 value

Diagnosis of
Diabetes (%) 56.3 65.6 0.153 62.5 59.4 0.632 64.6 57.3 0.265 73.4 60.9 48.4 0.009

Certainty of
diagnosis
(1-100) 18.8 26.0 0.033 23.8 21.0 0.405 24.4 20.4 0.241 31.6 20.7 15.0 <0.001

• Null hypothesis: no difference by the patient’s or doctor’s characteristics

 Variation in the diagnosis and certainty of a
Results
Variation in the diagnosis and certainty of
diagnosis of diabetes by patient race/ethnicity diagnosis of diabetes by patient gender
100 100.0
80 80.0

60 60.0

40 40.0

20 20.0

0 0.0
Diagnosis of diabetes (%) Certainty (1-100) Diagnosis of diabetes (%) Certainty (1-100)
Black Hispanic White Female Male

• Diagnosis of diabetes varied significantly by • Diagnosis of diabetes varied by gender

race/ethnicity (P=0.009)
• Mean level of certainty of diagnosis of diabetes
• Mean level of certainty of diagnosis of diabetes varied significant by gender (P=0.033)
varied significantly by race/ethnicity (P=<0.001)

• Regarding the influence of doctor’s characteristics, there was no significant

differences in diabetes diagnoses by doctors gender or experience
Discussion
PRIMARY QUESTION OF
INTEREST
• What is the influence of
patient, provider and
organizational factors on
the variability of diagnosis
and management of a
major chronic disease –
diabetes?
THE PRIMARY QUESTION OF
INTEREST WAS ANSWERED
• Study findings suggest that patient factors
influence the variability of diagnosis and
management of diabetes
• Key takeaway:
• Findings suggest that a contributor to
disparities in the diagnosis and
management of diabetes may be the social
patterning that results from variable
decision making at the level of primary care
Discussion
SUMMARY OF RESULTS:
• Hypothesis: There is a difference in diagnosis and certainty of a diagnosis for patients presenting
with symptoms suggestive of diabetes by the patient’s characteristics and doctor’s characteristics----
Hypothesis was partially supported

• There is a difference in diagnosis and certainty of a diagnosis of diabetes by the patient’s

characteristics
• Diagnosis of diabetes varied significantly by race/ethnicity
• Mean level of certainty of diagnosis of diabetes varied significantly by race/ethnicity
• Mean level of certainty of diagnosis of diabetes varied significant by gender

• However, doctors characteristics had little influence on diagnosis and certainty of a diagnosis
of diabetes
Discussion
WHAT DOES IT ALL MEAN?
• Public health challenge
• To what extent are race/ethnic disparities in diabetes and its associated health care the
result of continued reinforcement of expected differences?
• Race/ethnicity appears to be more important in decision making than signs and
symptoms
• Mirrors race/ethnic variations in diabetes in the USA
• Diabetes diagnoses may be missed by placing higher emphasis on Black and
Hispanic patients rather than on symptom presentation.
• Researching these subjects in combination with other approaches may help reduce
the widely reported and worrisome disparities in the deliver of the US health care
 Limitations/Future research

DO YOU TRUST THE RESULTS? TO BE IMPROVED WHAT'S NEXT?

• Clinical Validity • Sampling • More research!
• Video vignettes • Carefully selected random sample of • How much does
doctors instead of purposive sampling variability affect
• Replication
patient outcomes?
• Replication of the procedure within
• Multiple testing: • Interventions to reduce
the study helps validate the results of
variability?
the study • Multiple testing can increase the
likelihood of a type 1 error
• Balanced factorial design
• Reduce disparities in the
• Allows researchers to examine delivery of care in the
interactions between factors • Design Shortfalls
United States
• Requires fewer experimental subjects • Difficult to reproduce study without
than alternative designs video vignettes
References
• McKinlay, J., Piccolo, R., & Marceau, L. (2013). An additional cause of health care
disparities: the variable clinical decisions of primary care doctors. Journal of
Evaluation in Clinical Practice, 19(4), 664–673. https://doi-
org.sandiego.idm.oclc.org/10.1111/jep.12015
• Sainani, K. L. (2009). The Problem of Multiple Testing. The American Academy of
Physical Medicine and Rehabilitation, 1. doi:10.1016/j.pmrj.2009.10.00