Physician Practice Style and Barriers to Referral: Los Angeles Women’s Health Study Danielle Rose Ash, PhD VA HSR&D/Greater Los Angeles Care System Co-Authors: Diana Tisnado, PhD, Jennifer Malin, MD, PhD, May Lin Tao, MD, John Adams, PhD, Patricia Ganz, MD and Katherine Kahn, MD Funding from CA Breast Cancer Research Program, National Cancer Institute and VA-HSR&D

21 Starfield et al Pham et al 2007 Background Improved medical technology requires greater more specialists involved in care, particularly among elderly 1 Improved medical technology requires greater more specialists involved in care, particularly among elderly 1 Patients seeing numerous providers in numerous settings 2 Patients seeing numerous providers in numerous settings 2 Breast cancer care involves multiple physicians Breast cancer care involves multiple physicians

3Smith, Allwright, O'Dowd, 2008 Shared Care “…the planned delivery of care for patients with a chronic condition, informed by an enhanced information exchange over and above routine discharge and referral letters” “…the planned delivery of care for patients with a chronic condition, informed by an enhanced information exchange over and above routine discharge and referral letters”

4 Specific Aims Examine physician report of co-managing care v. other styles Examine physician report of co-managing care v. other styles Examine variations in physician practice style Examine variations in physician practice style

5 Los Angeles Women’s Health Study Data Collection Population-based study of women >50 identified as newly diagnosed with breast cancer by RCA in Los Angeles County, women completed detailed CATI (64% response rate) Women identified 477 physicians providers who delivered, recommended or discussed possible use of treatments Analytic cohort: 111 medical oncologists, 66 radiation oncologists and 171 surgeons in 298 offices (N=348) Final response rate was 76%

6 A 65-year-old woman with well-controlled diabetes, has been newly diagnosed with breast cancer Domain 1: Approach to the Patient Domain 1: Approach to the Patient Establish goals for cancer treatment and prognosis Establish goals for cancer treatment and prognosis Domain 2: Decision-making Domain 2: Decision-making Type of breast surgery Type of breast surgery Domain 3: Treatment of Signs, Symptoms and Co- morbidities Domain 3: Treatment of Signs, Symptoms and Co- morbidities Managing diabetes Managing diabetes

7 Physician Practice Style I provide this care myself without much input from another clinician I provide this care myself without much input from another clinician I co-manage or decide jointly about this care with another clinician I co-manage or decide jointly about this care with another clinician I refer patients to another clinician for this aspect of care I refer patients to another clinician for this aspect of care I am not involved in this aspect of care I am not involved in this aspect of care

8 Predicting Physician Practice Style PHYSICIAN PRACTICE STYLE Independent Co-manage Refer to other MDs Do not handle care PHYSICIAN CHARACTERISTICS - Age, Gender and Specialty FINANCIAL CHARACTERISTICS - Reimbursement, Financial Incentives to Services PRACTICE CHARACTERISTICS -Practice Setting and Size -# New Cancer Patients/Month -Tumor Board Participation - Barriers to Referrals: Provider Network Restrictions

9 Analytic Methods Multivariate logistic regression Multivariate logistic regression Present predicted probabilities Present predicted probabilities Weighted for provider non-response Weighted for provider non-response Adjusted for clustering at the physician office level Adjusted for clustering at the physician office level Bonferroni adjustment for multiple comparisons Bonferroni adjustment for multiple comparisons Tested for interactions Tested for interactions

10 40% of Physicians Report Co-Managing the Establishment of Cancer Treatment Goals p<0.001 for specialty

11 Co-management by Provider Network Restrictions: Approach to the Patient p<0.01 for provider network restrictions, adjusting for physician, financial and practice setting characteristics

12 Physician Practice Style in Management of Diabetes p<0.001 for specialty

13 Co-management by Provider Network Restrictions: Treatment of Diabetes Adjusting for physician, financial and practice setting characteristics

14 Conclusions Rates of co-management Rates of co-management Highest rates for approach to patients Highest rates for approach to patients Lower rates for decision-making and treatment of signs, symptoms and co-morbidities Lower rates for decision-making and treatment of signs, symptoms and co-morbidities Variations in practice style by specialty and practice setting characteristics Variations in practice style by specialty and practice setting characteristics Provider network restrictions were associated with less co-management Provider network restrictions were associated with less co-management

15 Limitations Generalizability Generalizability 21% of physicians reported network restrictions to high-quality referrals in Los Angeles County 21% of physicians reported network restrictions to high-quality referrals in Los Angeles County National data show provider network restrictions are prevalent in HMOs and non-HMO settings National data show provider network restrictions are prevalent in HMOs and non-HMO settings Clinical scenarios Clinical scenarios Social desirability bias Social desirability bias

16 Policy Implications Co-management may address fragmentation in the health care system Co-management may address fragmentation in the health care system Co-management rates across domains are less than 50% Co-management rates across domains are less than 50% Next steps need to analyze: Next steps need to analyze: Does co-managed care improve process of care and patient outcomes? Does co-managed care improve process of care and patient outcomes? Cost trade-offs associated with co-managed care Cost trade-offs associated with co-managed care

Thank you!

18 LA Women’s Health Study – Data Collection Rapid Case Ascertainment identified women 50 and older with incident breast cancer in LA (excluding Asian women years) N=2,745 Patients with incident breast cancer 50 years and older located N= 2,306 Complete LA Women’s Health Study baseline survey. Response rate 55%, N=1,269

19 Final response rate was 76%, 67% for medical oncologists, 89% for radiation oncologists and 80% for surgeons. Analytic cohort defined as: 111 medical oncologists, 66 radiation oncologists and 171 surgeons in 298 offices (N=348) 477 unique medical oncologists, radiation oncologists and general or breast surgeons identified & targeted for provider survey Women identified physicians (n=747) as fulfilling roles associated with medical oncologists (n=251), radiation oncologists (n=122) or surgeons (n=374)

20Adjusting for physician, financial and practice setting characteristics Practice Style by Provider Network Restrictions: Management of Diabetes Co-managed CareIndependent Practice Style p<0.01 for provider network restrictions for independent practice style

21 Provider Network Restrictions Associated with less co-management Associated with less co-management Approach to the patient Approach to the patient Decision-making: radiation therapy Decision-making: radiation therapy Treatment: Prescribing opiates for pain Treatment: Prescribing opiates for pain Never associated with more co-management Never associated with more co-management Associated with more independent practice style Associated with more independent practice style Decision-making: radiation therapy Decision-making: radiation therapy Treatment: arm symptoms, diabetes Treatment: arm symptoms, diabetes

22Adjusting for physician, financial and practice setting characteristics Practice Style by Provider Network Restrictions: Approach to Patient CoManagement StyleIndependent Practice Style p<0.01 for provider network restrictions

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