Social science insights into improving workforce effectiveness: examples from the developing field of hospital medicine

The pace of change in medical practice and health policy: collision or coexistence?

Medical practice and health policy are both changing rapidly. While the adopting of changes is not new for physicians, the pace of change in standards of care, marked by advances and reversals, has accelerated over the course of the past decade. A recurring new theme in medical practice has been an emphasis on tailoring treatment plans to individual patients. Physicians have had to simultaneously absorb new processes in the health care system brought about by the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 and the Affordable Care Act (ACA) in 2010. The ability of physicians to maintain standards of care that focus on individual patients may conflict with changes resulting from new health policies that emphasize population health management. Primary care physicians may be one of the few collective voices capable of identifying areas where population-level health policies conflict with the care of individual patients, and policymakers should include practicing primary care physicians in the form of community boards in order to ensure the development of new health policies that provide sustainable high-value patient care.

Is blood thicker than water? Peer effects in stent utilization among Floridian cardiologists

Variations in physician practice are pervasive and costly, and may be harmful. The objective of much policy in the West is to increase the interconnectedness of physicians, furthering the transfer of information and thus reducing variation. This study tests whether physicians are influenced by the practice of peers, or if propensity, mere context or sorting of like-minded physicians better explain similarities and differences in practice. We study US cardiologists who place coronary stents into patients with blocked arteries around the heart. Organized in locally competing physician groups and also as solo practitioners, they see patients in offices, but insert the stents at a shared production facility - the cath lab. We examine their use of the popular drug-eluting coronary stents between their launch and rapid adoption in early 2003, and through the period of late 2006 in which private and public reports of serious late side-effects eventually led to reductions in use. Our analyses use administrative claims data on nearly 1000 cardiologists and their patients in Florida, USA, merged with Florida physician licensure data. Collectively these physicians used these stents nearly a quarter of a million times in the 4 year period reviewed. Pooled and panel linear regressions for device utilization by a physicians are estimated using measures of peer utilization, physician characteristics and controls for unobservable physician characteristics, common shocks and selection effects. We find strong evidence for intra-group but against inter-group practice spillovers. Even when sharing the same lab, competing cardiologists did not appear to correlate practices. Our results are consistent with a view that policies aimed at increasing the interconnectedness of physicians must first consider the organizational barriers and competitive forces that can stymie knowledge transfer even among physicians working closely together.