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Schwab SD, Singh M. How power shapes behavior: Evidence from physicians. Science 2024; 384:802-808. [PMID: 38753782 DOI: 10.1126/science.adl3835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 03/22/2024] [Indexed: 05/18/2024]
Abstract
Power-the asymmetric control of valued resources-affects most human interactions. Although power is challenging to study with real-world data, a distinctive dataset allowed us to do so within the critical context of doctor-patient relationships. Using 1.5 million quasi-random assignments in US military emergency departments, we examined how power differentials between doctor and patient (measured by using differences in military ranks) affect physician behavior. Our findings indicate that power confers nontrivial advantages: "High-power" patients (who outrank their physician) receive more resources and have better outcomes than equivalently ranked "low-power" patients. Patient promotions even increase physician effort. Furthermore, low-power patients suffer if their physician concurrently cares for a high-power patient. Doctor-patient concordance on race and sex also matters. Overall, power-driven variation in behavior can harm the most vulnerable populations in health care settings.
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Affiliation(s)
- Stephen D Schwab
- Department of Management, University of Texas at San Antonio, San Antonio, TX, USA
| | - Manasvini Singh
- Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA, USA
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Miyawaki A, Jena AB, Burke LG, Figueroa JF, Tsugawa Y. Association Between Emergency Physician's Age and Mortality of Medicare Patients Aged 65 to 89 Years After Emergency Department Visit. Ann Emerg Med 2023; 82:301-312. [PMID: 36964007 DOI: 10.1016/j.annemergmed.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 03/26/2023]
Abstract
STUDY OBJECTIVE To determine the association between emergency physicians' ages and patient mortality after emergency department visits. METHODS This observational study used a 20% random sample of Medicare fee-for-service beneficiaries aged 65 to 89 years treated by emergency physicians at EDs from 2016 to 2017. We investigated whether 7-day mortality after ED visits differed by the age of the emergency physician, adjusting for patient and physician characteristics and hospital fixed effects. RESULTS We observed 2,629,464 ED visits treated by 32,570 emergency physicians (mean age 43.5). We found that patients treated by younger emergency physicians had lower mortality rates compared with those treated by older physicians. Adjusted 7-day mortality was 1.33% for patients treated by emergency physicians aged less than 40 years, 1.36% (adjusted difference, 0.03%; 95% confidence interval [CI], -0.001% to 0.06%) for physicians ages 40 to 49, 1.40% (0.08%; 95% CI 0.04% to 0.12%) for physicians ages 50 to 59, and 1.43% (0.11%; 95% CI 0.06% to 0.16%) for those with a physician age of 60 years and more. Similar patterns were observed when stratified by the patient's disposition (discharged vs admitted), and the association was more pronounced for patients with higher severity of illness. CONCLUSIONS Medicare patients aged 65 to 89 years treated by emergency physicians aged under 40 years had lower 7-day mortality rates than those treated by physicians aged 50 to 59 years and 60 years or older within the same hospital. Potential mechanisms explaining the association between emergency physician age and patient mortality (eg, differences in training received and other unobservable patient/physician characteristics) are uncertain and require further study.
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Affiliation(s)
- Atsushi Miyawaki
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA; Department of Medicine, Massachusetts General Hospital, Boston, MA; National Bureau of Economic Research, Cambridge, MA
| | - Laura G Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Jose F Figueroa
- Harvard Medical School, Boston, MA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
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Avdic D, Ivets M, Lagerqvist B, Sriubaite I. Providers, peers and patients. How do physicians' practice environments affect patient outcomes? JOURNAL OF HEALTH ECONOMICS 2023; 89:102741. [PMID: 36878022 DOI: 10.1016/j.jhealeco.2023.102741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 02/10/2023] [Accepted: 02/20/2023] [Indexed: 06/18/2023]
Abstract
We study how physicians' practice environments affect their treatment decisions and quality of care. Using clinical registry data from Sweden, we compare stent choices of cardiologists moving across hospitals over time. To disentangle changes in practice styles attributable to hospital- and peer group-specific factors, we exploit quasi-random variation on cardiologists working together on the same days. We find that migrating cardiologists' stent choices rapidly adapt to their new practice environment after relocation and are equally driven by the hospital and peer environments. In contrast, while decision errors increase, treatment costs and adverse clinical events remain largely unchanged despite the altered practice styles.
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Affiliation(s)
- Daniel Avdic
- Department of Economics, Deakin university, 70 Elgar Road, Burwood, VIC 3125, Australia.
| | - Maryna Ivets
- Ruhr Graduate School in Economics, Germany; CINCH-Health Economics Research Center, Germany
| | - Bo Lagerqvist
- UCR and Department of Medical Sciences, Uppsala University, Sweden
| | - Ieva Sriubaite
- Centre for Health Economics, Monash University, Australia
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Ghassemi M, Mohamed S. Machine learning and health need better values. NPJ Digit Med 2022; 5:51. [PMID: 35459793 PMCID: PMC9033858 DOI: 10.1038/s41746-022-00595-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 03/29/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Marzyeh Ghassemi
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA. .,Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA. .,CIFAR AI Chair, Vector Institute, Toronto, Ontario, M5G 1M1, Canada.
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Chou SC, Chang YSC, Chen PC, Schuur JD, Weiner SG. Hospital Occupancy and its Effect on Emergency Department Evaluation. Ann Emerg Med 2021; 79:172-181. [PMID: 34756449 DOI: 10.1016/j.annemergmed.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 08/12/2021] [Accepted: 08/23/2021] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE To examine whether hospital occupancy was associated with increased testing and treatment during emergency department (ED) evaluations, resulting in reduced admissions. METHODS We analyzed the electronic health records of an urban academic ED. We linked data from all ED visits from October 1, 2010, to May 29, 2015, with daily hospital occupancy (inpatients/total staffed beds). Outcome measures included the frequency of laboratory testing, advanced imaging, medication administration, and hospitalizations. We modeled each outcome using multivariable negative binomial or logistic regression, as appropriate, and examined their association with daily hospital occupancy quartiles, controlling for patient and visit characteristics. We calculated the adjusted outcome rates and relative changes at each daily hospital occupancy quartile using marginal estimating methods. RESULTS We included 270,434 ED visits with a mean patient age of 48.1 (standard deviation 19.8) years; 40.1% were female, 22.8% were non-Hispanic Black, and 51.5% were commercially insured. Hospital occupancy was not associated with differences in laboratory testing, advanced imaging, or medication administration. Compared with the first quartile, the third and fourth quartiles of daily hospital occupancy were associated with decreases of 1.5% (95% confidence interval [CI] -2.9 to -0.2; absolute change -0.6 percentage points [95% CI -1.2 to -0.1]) and 4.6% (95% CI -6.0 to -3.2; absolute change -1.9 percentage points [95% CI -2.5 to -1.3]) in hospitalizations, respectively. CONCLUSION The lack of association between hospital occupancy and laboratory testing, advanced imaging, and medication administration suggest that changes in ED testing or treatment did not facilitate the decrease in admissions during periods of high hospital occupancy.
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Affiliation(s)
- Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI.
| | - Yeu-Shin C Chang
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Paul C Chen
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
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Khidir H, McWilliams JM, O’Malley AJ, Zaborski L, Landon BE, Smulowitz PB. Analysis of Consistency in Emergency Department Physician Variation in Propensity for Admission Across Patient Sociodemographic Groups. JAMA Netw Open 2021; 4:e2125193. [PMID: 34546373 PMCID: PMC8456378 DOI: 10.1001/jamanetworkopen.2021.25193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Sociodemographic disparities in health care and variation in physician practice patterns have been well documented; however, the contribution of variation in individual physician care practices to health disparities is challenging to quantify. Emergency department (ED) physicians vary in their propensity to admit patients. The consistency of this variation across sociodemographic groups may help determine whether physician-specific factors are associated with care differences between patient groups. OBJECTIVE To estimate the consistency of ED physician admission propensities across categories of patient sex, race and ethnicity, and Medicaid enrollment. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed Medicare fee-for-service claims for ED visits from January 1, 2016, to December 31, 2019, in a 10% random sample of hospitals. The allocation of patients to ED physicians in the acute care setting was used to isolate physician-level variation in admission rates that reflects variation in physician decision-making. Multi-level models with physician random effects and hospital fixed effects were used to estimate the within-hospital physician variation in admission propensity for different patient sociodemographic subgroups and the covariation in these propensities between subgroups (consistency), adjusting for primary diagnosis and comorbidities. MAIN OUTCOMES AND MEASURES Admission from the ED. RESULTS The analysis included 4 567 760 ED visits involving 2 334 361 beneficiaries and 15 767 physicians in 396 EDs. The mean (SD) age of the beneficiaries was 78 (8.2) years, 2 700 661 visits (59.1%) were by women, and most patients (3 839 055 [84.1%]) were not eligible for Medicaid. Of 4 473 978 race and ethnicity reports on enrollment, 103 699 patients (2.3%) were Asian/Pacific Islander, 421 588 (9.4%) were Black, 257 422 (5.8%) were Hispanic, and 3 691 269 (82.5%) were non-Hispanic White. Within hospitals, adjusted rates of admission were higher for men (36.8%; 95% CI, 36.8%-36.9%) than for women (33.7%; 95% CI, 33.7%-33.8%); higher for non-Hispanic White (36.0%; 95% CI, 35.9%-36.0%) than for Asian/Pacific Islander (33.6%; 95% CI, 33.3%-33.9%), Black (30.2%; 95% CI, 30.0%-30.3%), or Hispanic (31.1%; 95% CI, 30.9%-31.2%) beneficiaries; and higher for beneficiaries dually enrolled in Medicaid (36.3%; 95% CI, 36.2%-36.5%) than for those who were not (34.7%; 95% CI, 34.7%-34.8%). Within hospitals, physicians varied in the percentage of patients admitted, ranging from 22.4% for physicians at the 10th percentile to 47.6% for physicians at the 90th percentile of the estimated distribution. Physician admission propensities were correlated between men and women (r = 0.99), Black and non-Hispanic White patients (r = 0.98), and patients who were dually enrolled and not dually enrolled in Medicaid (r = 0.98). CONCLUSIONS AND RELEVANCE This cross-sectional study indicated that, although overall rates of admission differ systematically by patient sociodemographic factors, an individual physician's propensity to admit relative to other physicians appears to be applied consistently across sociodemographic groups of patients.
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Affiliation(s)
- Hazar Khidir
- Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts
- Now with Yale School of Medicine, New Haven, Connecticut
| | | | - A. James O’Malley
- Department of Biomedical Data Science, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Lawrence Zaborski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Peter B. Smulowitz
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester
- Milford Regional Medical Center, Milford, Massachusetts
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Smulowitz PB, O’Malley AJ, Zaborski L, McWilliams JM, Landon BE. Variation In Emergency Department Admission Rates Among Medicare Patients: Does The Physician Matter? Health Aff (Millwood) 2021; 40:251-257. [DOI: 10.1377/hlthaff.2020.00670] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Peter B. Smulowitz
- Peter B. Smulowitz is an assistant professor of emergency medicine in the Department of Emergency Medicine at Beth Israel Deaconess Medical Center, in Boston, Massachusetts, and chief medical officer at Milford Regional Medical Center, in Milford, Massachusetts
| | - A. James O’Malley
- A. James O’Malley is a professor of biomedical data science at the Dartmouth Institute for Health Policy and Clinical Practice and in the Department of Biomedical Data Science at the Geisel School of Medicine at Dartmouth, in Hanover, New Hampshire
| | - Lawrence Zaborski
- Lawrence Zaborski is a senior statistical programmer in the Department of Health Care Policy at Harvard Medical School, in Boston
| | - J. Michael McWilliams
- J. Michael McWilliams is the Warren Alpert Foundation Professor of Health Care Policy in the Department of Health Care Policy at Harvard Medical School and a professor of medicine and general internist at Brigham and Women’s Hospital, in Boston, Massachusetts
| | - Bruce E. Landon
- Bruce E. Landon is a professor of health care policy in the Department of Health Care Policy at Harvard Medical School and a professor of medicine and practicing internist at Beth Israel Deaconess Medical Center
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Chang CY, Baugh CW, Brown CA, Weiner SG. Association Between Emergency Physician Length of Stay Rankings and Patient Characteristics. Acad Emerg Med 2020; 27:1002-1012. [PMID: 32569439 DOI: 10.1111/acem.14064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 06/09/2020] [Accepted: 06/17/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Emergency physicians are commonly compared by their patients' length of stay (LOS). We test the hypothesis that LOS is associated with patient characteristics and that accounting for these features impacts physician LOS rankings. METHODS This was a retrospective observational study of all encounters at an emergency department in 2010 to 2015. We compared the characteristics of patients seen by physicians in different quartiles of LOS. Primary outcome was variation in patient characteristics at time of physician assignment (age, sex, comorbidities, Emergency Severity Index [ESI], and chief complaint) across LOS quartiles. We also quantified the change in LOS rankings after accounting for difference in characteristics of patients seen by different physicians. RESULTS A total of 264,776 encounters seen by 62 attending physicians met inclusion criteria. Physicians in the longest LOS quartile saw patients who were older (age = 49.1 vs 48.6 years, difference = +0.5 years, 95% confidence interval [CI] = 0.3 to 0.7) with more comorbidities (Gagne score = 1.3 vs. 0.9, difference = +0.4, 95% CI = 0.4 to 0.4) and higher acuity (ESI = 2.8 vs. 2.9, difference = -0.1, 95% CI = 0.1 to 0.1) than physicians in the shortest LOS quartile. The odds ratio (OR) of physicians in the longest LOS quartile seeing patients over age 50 compared to the shortest LOS quartile was 1.1 (95% CI = 1.0 to 1.1); the OR of physicians in the longest LOS quartile seeing patients with ESI of 1 or 2 was also 1.1 (95% CI = 1.0 to 1.1). Accounting for variation in patient characteristics seen by different physicians resulted in substantial reordering of physician LOS rankings: 62.9% (39/62) of physicians reclassified into a different quartile with mean absolute percentile change of 25.8 (95% CI = 20.3 to 31.3). A total of 62.5% (10/16) of physicians in the shortest LOS quartile and 56.3% (9/16) in the longest LOS quartile moved into a different quartile after accounting for variation in patient characteristics. CONCLUSIONS Length of stay was significantly associated with patient characteristics, and accounting for variation in patient characteristics resulted in substantial reordering of relative physician rankings by LOS. Comparisons of emergency physicians by LOS that do not account for patient characteristics should be reconsidered.
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Affiliation(s)
- Cindy Y. Chang
- From the Department of Emergency Medicine Brigham and Women's Hospital Boston MA USA
- and the Department of Emergency Medicine Harvard Medical School Boston MA USA
| | - Christopher W. Baugh
- From the Department of Emergency Medicine Brigham and Women's Hospital Boston MA USA
- and the Department of Emergency Medicine Harvard Medical School Boston MA USA
| | - Calvin A. Brown
- From the Department of Emergency Medicine Brigham and Women's Hospital Boston MA USA
- and the Department of Emergency Medicine Harvard Medical School Boston MA USA
| | - Scott G. Weiner
- From the Department of Emergency Medicine Brigham and Women's Hospital Boston MA USA
- and the Department of Emergency Medicine Harvard Medical School Boston MA USA
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