Physician Practice Style and Barriers to Referral: Los Angeles Women’s Health Study

1. 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

2. Background • Improved medical technology requires greater more specialists involved in care, particularly among elderly1 • Patients seeing numerous providers in numerous settings2 • Breast cancer care involves multiple physicians 1 Starfield et al 2005 2 Pham et al 2007

3. 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” Smith, Allwright, O'Dowd, 2008

4. Specific Aims • Examine physician report of co-managing care v. other styles • 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, 2000 1224 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 • Establish goals for cancer treatment and prognosis • Domain 2: Decision-making • Type of breast surgery • Domain 3: Treatment of Signs, Symptoms and Co-morbidities • Managing diabetes

7. Physician Practice Style • I provide this care myself without much input from 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 am not involved in this aspect of care

8. Predicting Physician Practice Style PHYSICIAN CHARACTERISTICS - Age, Gender and Specialty PHYSICIAN PRACTICE STYLE Independent Co-manage Refer to other MDs Do not handle care 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 • Present predicted probabilities • Weighted for provider non-response • Adjusted for clustering at the physician office level • Bonferroni adjustment for multiple comparisons • 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 • Highest rates for approach to patients • Lower rates for decision-making and treatment of signs, symptoms and co-morbidities • Variations in practice style by specialty and practice setting characteristics • Provider network restrictions were associated with less co-management

15. Limitations • Generalizability • 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 • Clinical scenarios • Social desirability bias

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

17. 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 55-70 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. Women identified physicians (n=747) as fulfilling roles associated with medical oncologists (n=251), radiation oncologists (n=122) or surgeons (n=374) 477 unique medical oncologists, radiation oncologists and general or breast surgeons identified & targeted for provider survey 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)

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

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

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