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Cited by 37Clinical Reasoning and Diagnostic SkillsClinical practice guidelines implementationPrimary Care and Health Outcomes

Diagnostic Certainty as a Source of Medical Practice Variation in Coronary Heart Disease: Results from a Cross-National Experiment of Clinical Decision Making

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Lutfey, Karen E., Link, Carol L., Marceau, Lisa D., Grant, Richard W., Adams, Ann, Arber, Sara, Siegrist, Johannes, Bönte, Markus +2 more·2009·Medical Decision Making
DOI 10.1177/0272989x09331811PMC PMC3755454
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Abstract

The authors examined physician diagnostic certainty as one reason for cross-national medical practice variation. Data are from a factorial experiment conducted in the United States, the United Kingdom, and Germany, estimating 384 generalist physicians' diagnostic and treatment decisions for videotaped vignettes of actor patients depicting a presentation consistent with coronary heart disease (CHD). Despite identical vignette presentations, the authors observed significant differences across health care systems, with US physicians being the most certain and German physicians the least certain (P < 0.0001). Physicians were least certain of a CHD diagnoses when patients were younger and female (P < 0.0086), and there was additional variation by health care system (as represented by country) depending on patient age (P < 0.0100) and race (P < 0.0021). Certainty was positively correlated with several clinical actions, including test ordering, prescriptions, referrals to specialists, and time to follow-up.

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  • Many assumption studies attempted to make their vignettes as realistic as possible by having them validated by clinicians and by having participants view/read the vignettes as part of a normal day at work.

    “many of the assumption studies attempted to make their vignettes as realistic as possible by having them validated by clinicians [25–41] and also by having participants view/read the vignettes as part of a normal day at work [27–36, 39, 41].”

    From Implicit bias in healthcare professionals: a systematic review (2017) · cites this paper as [29]

  • Eight articles appeared to refer to the same data collected in a single cross-country comparison study, and a further two articles analysed the same data.

    “eight articles appeared to refer to the same data collected in a single cross-country comparison study [27–32, 34, 35] and a further two articles analysed the same data [45, 47].”

    From Implicit bias in healthcare professionals: a systematic review (2017) · cites this paper as [29]

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References 56 · Cited by 37

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  1. [1]Institute of Medicine Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare Washington, D.C The National Academies Press 2003 25032386
  2. [2]Ayanian JZ Epstein AM Differences in the use of procedures between women and men hospitalized for coronary heart disease N Engl J Med 1991 325 4 221 5 2057022
  3. [3]Schwartz LM Fisher ES Tosteson NA Woloshin S Chang CH Virnig BA Treatment and health outcomes of women and men in a cohort with coronary artery disease Arch Intern Med 1997 157 14 1545 51 9236556
  4. [4]Popescu I Vaughan-Sarrazin MS Rosenthal GE Differences in mortality and use of revascularization in black and white patients with acute MI admitted to hospitals with and without revascularization services JAMA 2007 297 22 2489 95 17565083
  5. [5]Holmes JS Arispe IE Moy E Heart disease and prevention: race and age differences in heart disease prevention, treatment, and mortality Med Care 2005 43 3 Suppl I33 41 15746589
  6. [6]James TL Feldman J Mehta SD Physician variability in history taking when evaluating patients presenting with chest pain in the emergency department Acad Emerg Med 2006 13 2 147 52 16436792
  7. [7]Martin R Gordon EE Lounsbury P Gender disparities in the attribution of cardiac-related symptoms: contribution of common sense models of illness Health Psychol 1998 17 4 346 57 9697944
  8. [8]McKinlay JB Potter DA Feldman HA Non-medical influences on medical decision-making Soc Sci Med 1996 42 5 769 76 8685745
  9. [9]Armstrong DL Strogatz D Wang R United States coronary mortality trends and community services associated with occupational structure, among blacks and whites, 1984–1998 Soc Sci Med 2004 58 11 2349 61 15047090
  10. [10]Fincher C Williams JE MacLean V Allison JJ Kiefe CI Canto J Racial disparities in coronary heart disease: a sociological view of the medical literature on physician bias Ethn Dis 2004 14 3 360 71 15328937
  11. [11]McKinlay JB Link CL Freund KM Marceau LD O’Donnell AB Lutfey KE Sources of Variation in Physician Adherence with Clinical Guidelines: Results from a Factorial Experiment Journal of General Internal Medicine 2007 22 3 289 96 17356957 PMC1824760
  12. [12]Arber S McKinlay JB Adams A Marceau LD Link CL O’Donnell AB Patient Characteristics and Inequalities in Doctors’ Diagnostic and Management Strategies relating to CHD: A Video-simulation Experiment Social Science and Medicine 2006 62 1 103 15 16002197
  13. [13]Bird CE Fremont AM Bierman AS Wickstrom S Shah M Rector T Does quality of care for cardiovascular disease and diabetes differ by gender for enrollees in managed care plans? Womens Health Issues 2007 17 3 131 8 17434752
  14. [14]Fremont AM Correa-de-Araujo R Hayes SN Gender disparities in managed care: it’s time for action Womens Health Issues 2007 17 3 116 9 17512754
  15. [15]Wexler DJ Grant RW Meigs JB Nathan DM Cagliero E Sex disparities in treatment of cardiac risk factors in patients with type 2 diabetes Diabetes Care 2005 28 3 514 20 15735180
  16. [16]Britt H Bhasale A Miles DA Meza A Sayer GP Angelis M The sex of the general practitioner: a comparison of characteristics, patients, and medical conditions managed Med Care 1996 34 5 403 15 8614163
  17. [17]Collins E Katona C Orrell M Management of depression in the elderly by general practitioners: II. Attitudes to ageing and factors affecting practice Fam Pract 1995 12 1 12 7 7665032
  18. [18]Armstrong D Fry J Armstrong P Doctors’ perceptions of pressure from patients for referral BMJ 1991 302 6786 1186 8 2043816 PMC1669899
  19. [19]Curoe A Kralewski J Kaissi A Assessing the cultures of medical group practices J Am Board Fam Pract 2003 16 5 394 8 14645329
  20. [21]Goodman DC Grumbach K Does having more physicians lead to better health system performance? JAMA 2008 299 3 335 7 18212319
  21. [22]Wennberg JE Fisher ES Skinner JS Geography and the debate over Medicare reform Health Aff (Millwood) 2002 Suppl Web Exclusives W96 114 12703563
  22. [23]Weisz D Gusmano MK Rodwin VG Gender and the treatment of heart disease in older persons in the United States, France, and England: a comparative, population-based view of a clinical phenomenon Gend Med 2004 1 1 29 40 16115581
  23. [24]Pilote L Saynina O Lavoie F McClellan M Cardiac procedure use and outcomes in elderly patients with acute myocardial infarction in the United States and Quebec, Canada, 1988 to 1994 Med Care 2003 41 7 813 22 12835605
  24. [25]McKinlay J Link C Arber S Marceau L O’Donnell A Adams A How do Doctors in Different Countries Manage the Same Patient? Results of a Factorial Experiment Health Services Research 2006 41 6 2182 2200 [Erratum in 41(6):2303.] PMC1955316 17116115
  25. [26]Gurjeva OS Bukhman G Murphy S Cannon CP Treatment and outcomes of eastern Europeans with coronary syndromes in OPUS-TIMI 16 Int J Cardiol 2005 100 1 101 7 15820292
  26. [27]Kramer JM Newby LK Chang WC Simes RJ Van de Werf F Granger CB International variation in the use of evidence-based medicines for acute coronary syndromes Eur Heart J 2003 24 23 2133 41 14643274
  27. [28]Pauker SG Kassirer JP The threshold approach to clinical decision making N Engl J Med 1980 302 20 1109 17 7366635
  28. [29]Pauker SG Kassirer JP Decision analysis N Engl J Med 1987 316 5 250 8 3540670
  29. [30]van Ryn M Research on the provider contribution to race/ethnicity disparities in medical care Med Care 2002 40 1 Suppl I140 51 11789627
  30. [31]Balsa AI McGuire TG Meredith LS Testing for statistical discrimination in health care Health Serv Res 2005 40 1 227 52 15663711 PMC1361135
  31. [32]Lutfey KE Ketcham JD Patient and provider assessments of adherence and the sources of disparities: evidence from diabetes care Health Serv Res 2005 40 6 Pt 1 1803 17 16336549 PMC1361226
  32. [33]Villaire M Mayer G Chronic illness management and health literacy: an overview J Med Pract Manage 2007 23 3 177 81 18225822
  33. [34]Safeer RS Keenan J Health literacy: the gap between physicians and patients Am Fam Physician 2005 72 3 463 8 16100861
  34. [35]Bittner V Angina pectoris: reversal of the gender gap Circulation 2008 117 12 1505 7 18362242
  35. [36]Hemingway H Langenberg C Damant J Frost C Pyorala K Barrett-Connor E Prevalence of angina in women versus men: a systematic review and meta-analysis of international variations across 31 countries Circulation 2008 117 12 1526 36 18347213
  36. [37]Shaw LJ Lewis JF Hlatky MA Hsueh WA Kelsey SF Klein R Women’s Ischemic Syndrome Evaluation: current status and future research directions: report of the National Heart, Lung and Blood Institute workshop: October 2–4, 2002: Section 5: gender-related risk factors for ischemic heart disease Circulation 2004 109 6 e56 8 14970127
  37. [38]McKinlay JB Some contributions from the social system to gender inequalities in heart disease J Health Soc Behav 1996 37 1 1 26 8820308
  38. [39]Marrugat J Gil M Sala J Sex differences in survival rates after acute myocardial infarction J Cardiovasc Risk 1999 6 2 89 97 10353068
  39. [40]Light DW Universal health care: lessons from the British experience Am J Public Health 2003 93 1 25 30 12511379 PMC1447686
  40. [41]Altenstetter C Insights from health care in Germany Am J Public Health 2003 93 1 38 44 12511381 PMC1447688
  41. [42]Fisher RA Statistical Methods, Experimental Design and Scientific Inference New York Oxford University Press 1990
  42. [43]Cohen JW Krauss NA Spending and Service Use Among People with the Fifteen Most Costly Medical Conditions Health Affairs 2003 22 2 129 38 12674416
  43. [44]Arber S McKinlay JB Adams A Marceau LD Link CL O’Donnell AB Influence of Patient Characteristics on Doctors’ Questioning and Lifestyle Advice for Coronary Heart Disease: A UK/US Video Experiment British Journal of General Practice 2004 54 506 673 678 15353053 PMC1326068
  44. [45]Balsa AI McGuire TG Statistical discrimination in health care J Health Econ 2001 20 6 881 907 11758051
  45. [47]Staniland JR Clamp SE de Dombal FT Solheim K Hansen S Ronsen K Presentation and diagnosis of patients with acute abdominal pain: comparisons between Leeds, U.K. and Akershus county, Norway Ann Chir Gynaecol 1980 69 6 245 50 7011161
  46. [49]Campbell S Reeves D Kontopantelis E Middleton E Sibbald B Roland M Quality of primary care in England with the introduction of pay for performance N Engl J Med 2007 357 2 181 90 17625132
  47. [50]Veloski J Tai S Evans AS Nash DB Clinical vignette-based surveys: a tool for assessing physician practice variation Am J Med Qual 2005 20 3 151 7 15951521
  48. [51]Peabody JW Luck J Glassman P Dresselhaus TR Lee M Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality JAMA 2000 283 13 1715 22 10755498
  49. [52]Dresselhaus TR Peabody JW Lee M Wang MM Luck J Measuring compliance with preventive care guidelines: standardized patients, clinical vignettes, and the medical record J Gen Intern Med 2000 15 11 782 8 11119170 PMC1495610
  50. [53]Robra BP Kania H Kuss O Schonfisch K Swart E Determinants of hospital admission--investigation by case vignettes Gesundheitswesen 2006 68 1 32 40 16463243
  51. [54]Brooks LR LeBlanc VR Norman GR On the difficulty of noticing obvious features in patient appearance Psychol Sci 2000 11 112 7 11273417
  52. [55]Eva KW Brooks LR The underweighting of implicitly generated diagnoses Acad Med 2000 75 Supplement 81 83 11031182
  53. [56]Lutfey KE Eva KW Gerstenberger E Link CL McKinlay JB The Cognitive Basis of Diagnostic and Treatment Disparities in Coronary Heart Disease: Results of a Factorial Experiment Unpublished manuscript 2008 PMC3120017 20420292

Authors
Lutfey, K. E., Link, C. L., Marceau, L. D., Grant, R. W., Adams, A., Arber, S., Siegrist, J., Bönte, M., von dem Knesebeck, O., & McKinlay, J. B.
Affiliations
  • New England Research Institutes (US)
  • Harvard University (US)
  • University of Warwick (GB)
  • University of Surrey (GB)
  • Dusseldorf University, Dusseldorf, Germany (JS); and University of Hamburg, Hamburg, Germany
  • Universität Hamburg (DE)
  • New England Research Institutes, Watertown, Massachusetts
Corresponding author
Lutfey, Karen E.
ORCID
Venue
Medical Decision Making
Publisher
SAGE Publications
Published
2009-05-21
Volume
29
Issue
5
Pages
606-618
ISSN
  • 0272-989X (ISSN-L)
  • 1552-681X
DOI
10.1177/0272989x09331811
PMC
PMC3755454
OpenAlex
W2161932708
Cited by
37
References
56
Citations by year
2025: 2 · 2024: 9 · 2023: 1 · 2022: 3 · 2021: 3 · 2020: 1 · 2019: 3 · 2018: 1 · 2017: 2 · 2016: 3 · 2014: 3 · 2013: 1 · 2012: 2
FWCI
1.22
Type
journal article
Language
en
Open access
Licence
journals.sagepub.com/page/policies/text-and-data-mining-license (tdm)
Locations
  • Medical Decision Making (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • Surrey Research Insight Open Access (The University of Surrey) (submittedVersion)
  • RePEc: Research Papers in Economics (submittedVersion)
Funders
  • National Institute for Health and Care Research (PC6/CSA04/01)
  • National Institute on Aging (AG 16747, R01AG016747)
Topics
  • Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
  • Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
Keywords
diagnostic certainty, clinical practice variation, coronary artery disease, clinical decision-making, cross-national comparison, health care system, vignette study, generalist physicians, sex differences in diagnosis, patient age, race, test ordering, specialist referral
MeSH terms
Aged, Coronary Disease, Decision Making, Female, Humans, Male, Middle Aged, Practice Patterns, Physicians', Uncertainty

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