Medical Practice Variation Among Primary Care Physicians: 1 Decade, 14 Health Services, and 3,238,498 Patient-Years

Abstract

Purpose: Variation in medical practice is associated with poorer health outcomes, increased costs, disparities in care, and increased burden on the public health system. In the present study, we sought to describe and assess inter- and intra-primary care physician variation, adjusted for patient and clinic characteristics, over a decade of practice and across a broad range of health services.

Methods: We assessed practice patterns of 251 primary care physicians in southern Israel. For each of 14 health services (imaging tests, cardiac tests, laboratory tests, and specialist visits) we described interphysician and intraphysician variation, adjusted for patient case mix and clinic characteristics, using the coefficient of variation. The adjusted rates were assessed by generalized linear negative-binomial mixed models.

Results: The variation between physicians was on average 3-fold greater than the variation of individual physician practice over the years. Services with low utilization were associated with greater inter- and intraphysician variation: r_s = (-0.58), P = .03 and r_s = (-0.39), P = .17, respectively. In addition, physician utilization ranks averaged over all health services were consistent across the 14 health services (intraclass correlation coefficient, 0.94; 95% CI, 0.93-0.95).

Conclusions: Our results show greater variation in practice patterns between physicians than for individual physicians over the years. It appears that the variation remains high even after adjustment for patient and clinic characteristics and that the individual physician utilization patterns are stable across health services. We propose that personal behavioral characteristics of medical practitioners might explain this variation.

Keywords: health care delivery/health services research; health services; medical practice variation; primary care.

Figure 1.

Inter- vs intraphysician variation and utilization rates. CEA = carcinoembryonic antigen; CT = computed tomography; CV = coefficient of variation; CXR = chest radiography; ED = emergency department; Hb = hemoglobin; MRI = magnetic resonance imaging; PSA = prostate-specific antigen; TSH = thyroid-stimulating hormone. Note: Health services are shown by inter- and intraphysician variation (x and y axis, respectively) and utilization rates (circle size). High inter- and intraphysician variation health services are positioned at the upper right, and low inter- and intraphysician variation health services are at lower left. Larger circle size indicates higher utilization rate.