Regional Variations in Health Care Intensity and Physician Perceptions of Quality of Care

  1. Brenda E. Sirovich, MD, MS;
  2. Daniel J. Gottlieb, MS;
  3. H. Gilbert Welch, MD, MPH; and
  4. Elliott S. Fisher, MD, MPH
  1. From the Veterans Affairs Medical Center Outcomes Group, White River Junction, Vermont, and the Center for Evaluative Clinical Sciences at Dartmouth College, Hanover, New Hampshire.

    Abstract

    Background: Research has documented dramatic differences in health care utilization and spending across U.S. regions with similar levels of patient illness. Although patient outcomes and quality of care have been found to be no better in regions of high health care intensity, it is unknown whether physicians in these regions feel more capable of providing good patient care than those in low-intensity regions.

    Objective: To determine whether physicians in high-intensity regions feel better able to care for patients than physicians in low-intensity regions.

    Design: Physician telephone survey.

    Setting: 51 metropolitan and 9 nonmetropolitan areas of the United States and a supplemental national sample.

    Participants: 10 577 physicians who provided care to adults in 1998 or 1999 were surveyed for the Community Tracking Study (response rate, 61%).

    Measurements: The End-of-Life Expenditure Index, a measure of spending that reflects differences in the overall quantity of medical services provided rather than differences in illness or price, was used to determine health care intensity in the physicians' community. Outcomes included physicians' perceived availability of clinical services, ability to provide high-quality care to patients, and career satisfaction.

    Results: Although the highest-intensity regions have substantially more hospital beds and specialists per capita, physicians in these regions reported more difficulty obtaining needed services for their patients. The proportion of physicians who felt able to obtain elective hospital admissions ranged from 50% in high-intensity regions to 64% in the lowest-intensity region (P < 0.001 for the relationship between intensity and perceived ability to obtain hospital admissions); the proportion of physicians who felt able to obtain high-quality specialist referrals ranged from 64% in high-intensity regions to 79% in low-intensity regions (P < 0.001). Compared with low-intensity regions, fewer physicians in high-intensity regions felt able to maintain good ongoing patient relationships (range, 62% to 70%; P < 0.001) or able to provide high-quality care (range, 72% to 77%; P = 0.009). In most cases, differences persisted but were attenuated in magnitude after adjustment for physician attributes, practice characteristics, and local market factors (for example, managed care penetration); the difference in perceived ability to provide high-quality care was no longer statistically significant (P = 0.099).

    Limitations: The cross-sectional design prevented demonstration of a causal relationship between intensity and physician perceptions of quality.

    Conclusion: Despite more resources, physicians in regions of high health care intensity did not report greater ease in obtaining needed services or greater ability to provide high-quality care.

    Article and Author Information

    • Disclaimer: The views expressed herein do not necessarily represent the views of the Department of Veterans Affairs or the U.S. government.

    • Acknowledgments: The authors thank James Reschovsky, PhD, of the Center for Studying Health System Change in Washington, DC, for his valuable comments on an earlier draft of the manuscript.

    • Grant Support: Dr. Sirovich is supported by a Veterans Affairs Career Development Award in HSR&D. This study was supported by a Research Enhancement Award from the Department of Veterans Affairs (03-098) to investigate the harms from excessive medical care. Financial support was also provided by grants from the Robert Wood Johnson Foundation and the National Institute of Aging (PO1 AG19783).

    • Potential Financial Conflicts of Interest: None disclosed.

    • Requests for Single Reprints: Brenda E. Sirovich, Veterans Affairs Outcomes Group (111B), Veterans Affairs Medical Center, White River Junction, VT 05009; e-mail, brenda.sirovich{at}dartmouth.edu.

    • Current Author Addresses: Drs. Sirovich and Welch: Veterans Affairs Outcomes Group, Veterans Affairs Medical Center, White River Junction, VT 05009.

    • Mr. Gottlieb and Dr. Fisher: Dartmouth College, 7251 Strasenburgh Hall, Hanover, NH 03755.

    • Author Contributions: Conception and design: B.E. Sirovich, D.J. Gottlieb, E.S. Fisher.

    • Analysis and interpretation of the data: B.E. Sirovich, D.J. Gottlieb, H.G. Welch, E.S. Fisher.

    • Drafting of the article: B.E. Sirovich.

    • Critical revision of the article for important intellectual content: D.J. Gottlieb, H.G. Welch, E.S. Fisher.

    • Final approval of the article: B.E. Sirovich, D.J. Gottlieb, H.G. Welch, E.S. Fisher.

    • Provision of study materials or patients: E.S. Fisher.

    • Statistical expertise: B.E. Sirovich, D.J. Gottlieb, E.S. Fisher.

    • Obtaining of funding: E.S. Fisher.

    • Administrative, technical, or logistic support: D.J. Gottlieb.

    • Collection and assembly of data: D.J. Gottlieb.

    Responses to this article

    • In response:
      • Brenda E Sirovich and
      • Elliott S. Fisher, MD, MPH
      Ann Intern Med published online October 26, 2009
    • Look for Locked-in Behavior
      • John C. Peirce
      Ann Intern Med published online October 26, 2009
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    1. Ann Intern Med May 2, 2006 vol. 144 no. 9 641-649
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