Two heads are better than one: Multi-physician practices improve heart patients' outcomes

Although single-physician practices still are dominant in the United States, multi-physician practices tend to provide better care for people who suffer heart attacks. Heart attack patients receive less-timely treatment and have worse chances of survival if they are treated by solo physicians rather than physicians from larger practices, according to a new study authored by Jonathan Ketcham, an assistant professor at the W. P. Carey School of Business.

Although single-physician practices still are dominant in the United States, multi-physician practices tend to provide better care for people who suffer heart attacks. Heart attack patients receive less-timely treatment and have worse chances of survival if they are treated by solo physicians rather than physicians from larger practices, according to a new study authored by Jonathan Ketcham, an assistant professor at the W. P. Carey School of Business.

The nationwide study, which analyzed the records of 116,671 patients covered by traditional Medicare in 1999, showed that solo practitioners' patients were less likely to receive cardiac catheterization and angioplasty on the day of their admission to the hospital after suffering heart attacks.

Survival rates also were lower for solo practitioners' patients, according to the study, "Physician Practice Size and Variations in Treatments and Outcomes: Evidence from Medicare Patients with Acute Myocardial Infarction."

A third fly solo

About a third of U.S. physicians are solo practitioners despite a decades-long trend toward group practices. That trend has cooled somewhat because of physicians' desire for autonomy, because of managed-care cost-cutting and because of the failure of economies of scale to meet expectations.

In the Medicare pool examined in the "Physician Practice Size and Variations in Treatments and Outcomes" study, 39 percent of the patients had solo physicians. The rest broke down as follows:

• 11 percent were with a physician group of six to nine members.
• 10 percent were with a group of 10-19 physicians.
• 7 percent: 20-49 physicians.
• 7 percent: 50 or more physicians.

The study published in the first 2007 issue of the journal Health Affairs was done by Jonathan Ketcham, assistant professor in the School of Health Management and Policy at the W. P. Carey School of Business; Laurence Baker, associate professor at Stanford University's Department of Health Research and Policy; and Donna MacIsaac, a data analyst at Stanford's Department of Health Research and Policy.

The Robert Wood Johnson Foundation sponsored the project, which Ketcham began while he was one of the foundation's Scholars in Health Research and Policy at the University of California, Berkeley.

Differences in treatment, outcomes

"We find that patients treated by solo physicians are less likely to receive cardiac catheterization and angioplasty within a day of admission and more likely to die than other patients in the same hospital, even after a number of patient and physician characteristics are accounted for," the study states. "These differences suggest that solo practitioners are less likely to follow guidelines calling for quick use of angioplasty."

Group physicians' patients were 10 percent to 12 percent more likely to receive catheterization and 10 percent to 26 percent more likely to receive angioplasty on the day of their hospital admission than were solo physicians' patients.

In an interview, Ketcham emphasized that their study found that the largest differences existed between solo physicians and everyone else, and that other small practices' outcomes were similar to those achieved by larger practices. The study lists ways in which multi-physician practices may prove superior care compared with solo practitioners:

• Better information technology
• Quicker implementation of care-improving practices
• Better access to clinical information and consultations through peers
• Narrower focus on certain types of patients
• More access to outside consultants
• More influence at hospitals

Should hospital staff be on special alert when a patient of a single-physician practice comes into the ER with a heart problem? "The hospital staff should pay attention to the quality of care provided by the solo cardiologists treating heart attack patients at their facilities," Ketcham says.

"The distinction here is that we study the attending physician, which is the one that is assigned to the patient once they are admitted to the hospital. This is typically not the patient's primary care physician."

Second opinions and sharing information

Is this a situation where a second opinion would help — or even be possible in an emergency situation? "A second opinion could be important to understand and interpret the results of the cardiac catheterization and the decision about what to do after that," Ketcham says.

"Other types of information sharing might also be important, such as discussing the guidelines or the latest research, or learning from each others' experiences. Non-solo practices might be better at sharing these types of information among their physicians." The study says the differing quality of treatment patterns and outcomes may be because of the solo physicians and because of the type of patients they have.

"For example, physicians who choose to be in solo practice might, on average, have different approaches to practice or different preferences about interactions with other physicians that ultimately influence the ways in which they provide care," the study states. "Similarly, patients of solo practitioners might have different views about treatment."

"For example, if such patients were less inclined toward catheterization or [angioplasty], our results might simply indicate differences in patients' preferences." Are solo practitioners averse to consultation? Is that why they are solo acts? "The differences might result from differences in solo physicians' willingness to consult with colleagues," Ketcham says.

"Alternatively it might be that solo physicians have a harder time sharing information with other physicians and learning from them. Another possibility is that non-solo physician groups might have processes in place that help monitor and improve the quality of care." Does going to a solo practitioner make it easier for a patient to resist treatment that might help?

"Our study indicates that it's less a matter of whether the patient receives treatment and more a matter of when," Ketcham says. "Guidelines developed by the American Heart Association and the American College of Cardiology state that patients who receive angioplasty should get it quickly, and cardiac catheterization typically precedes angioplasty."

"We find large differences in the chance that solo physicians' patients get catheterization and angioplasty on the first day of being admitted to the hospital for a heart attack. However, by 30 days after the heart attack, solo physicians' patients were almost as likely to have eventually received these treatments."

"Patient preferences or the dynamics of the physician-patient relationship might be more important in other contexts, but they aren't likely to explain the differences in treatment and survival that we found for heart attack patients." What other conclusions could be reached from the work?

"This is a nationwide study of traditional Medicare patients (those not in Medicare HMOs) who suffered heart attacks. Because we compared patients being treated in the same hospital, the differences we found don't result from different access to technology, living in rural areas, or other characteristics of the hospital or city," Ketcham says.

"From patients' perspectives, being treated by solo physicians for a heart attack made it less likely that they would receive beneficial treatment quickly, and somewhat more likely that they would die." The policy implications are less clear, Ketcham says, because they depend on what causes these differences.

"If the differences reflect different approaches to medicine by physicians who choose to become solo practitioners, then having those physicians join larger groups would not improve quality," Ketcham says. "Alternatively, if larger groups are undertaking activities that help physicians share information or improve quality in ways that solo practices cannot, then forming larger groups would improve care."

The study urges further research to determine what creates differences between solo-physician and group-practice care and outcomes and to learn whether they are found in settings beyond hospital care for heart attacks. "The ultimate goal of this work is to shed light on the importance of physician organizations on the experiences of patients and the quality of care they receive," Ketcham says.

"We'd like to find out how physician organizations influence care for other illnesses. We'd also like to get a better understanding of what creates these differences, so that we can know what to do about them and how to best improve quality for everyone."

Bottom line:

• Solo physicians' heart attack patients are less like to get catheterization and angioplasty on the day of their hospital admissions than are patients of multi-physician practices, and they are more likely to die.
• The largest differences existed between solo physicians and everyone else; small multi-physician practices' outcomes were approximately equal to those achieved by larger practices.
• Weaknesses in care can be offset by emphasizing second opinions and information-sharing among physicians; hospital staff also should pay attention to the quality of care provided by solo cardiologists.
• More research is needed on other care factors and other diseases.

29 percent were served by a practice of two to five physicians.