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Sources of practice variations in cardiology - The influence of clinical context, cost, physicians’ perceptions and practice considerations

Veena Manja, Gordon Guyatt, Sandra Monteiro, Susan Jack, Satyanarayana Lakshminrusimha, John You


Background: Practice variation is common and may represent variation in values and preferences in the setting of limited evidence regarding optimal care or indicate deficiencies in care. 

Methods: We administered a case-based survey to cardiologists in the United States and Canada. Participants selected their preferred management option and then rated the influence of 7 factors (safety, effectiveness, patient-centered care, efficiency, local hospital practice, medicolegal concerns and prior experience) on their decision using a scale of 1 (unimportant) to 7 (critically important). Follow-up questions explored knowledge and attitudes on healthcare costs. The relationship between management choice and perceived influence of each factor was examined using repeated measures ANOVA. Free text comments were analyzed using basic content analysis.

Results: One hundred and six cardiologists completed the survey. Respondents rated safety (5.8), effectiveness (5.7) and patient-centered care (5.7) as important determinants irrespective of their management choice. Cardiologists frequently (range 19%-87%) chose options not recommended by clinical practice guidelines (CPG), with individual cardiologists sometimes choosing guideline-suggested options and sometimes not. Differences in ratings of factors between those who chose guideline-suggested options and those who did not varied based on the case. Respondents considered cost to be important in decision-making; however, they did not feel well informed and, consequently, seldom discussed this with patients.

Conclusion: Cardiologists rate evidence-based practice as an important factor influencing their decision-making whether or not they make CPG-concordant choices. Sources of practice variation include case-context, local hospital practice and medicolegal concerns. Implementation strategies to improve high value patient-centered care should consider physicians’ perceptions of effectiveness of the management options. Successful strategies to improve patient-centered care will require engagement from physicians, particularly to understand how best to support their ability to counsel and involve patients when choosing treatment options and considering cost in these decisions. A deeper understanding of practice variation and its implications will require use of qualitative methods.


Cardiology, clinical context, clinical decision-making, clinical practice guidelines, evidence-based medicine, healthcare costs, high value care, management options, patient-centered care, person-centered healthcare, practice variations

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Wennberg, J.E. (2010). Tracking Medicine: A Researcher's Quest to Understand Health Care. Oxford: Oxford University Press.

Krumholz, H.M. (2013). Variations in health care, patient preferences, and high-quality decision making. Journal of the American Medical Association 310 (2) 151-152.

Wennberg, D.E., Kellett, M.A., Dickens, J.D., Malenka, D.J., Keilson, L.M. & Keller, R.B. (1996). The association between local diagnostic testing intensity and invasive cardiac procedures. Journal of the American Medical Association 275 (15) 1161-1164.

Lucas, F.L., Siewers, A.E., Malenka, D.J. & Wennberg, D.E. (2008). Diagnostic-therapeutic cascade revisited: coronary angiography, coronary artery bypass graft surgery, and percutaneous coronary intervention in the modern era. Circulation 118 (25) 2797-2802.

Shah, B.R., McCoy, L.A., Federspiel, J.J., Mudrick, D., Cowper, P.A., Massoudi, F.A., Lytle, B.L., Green, C.L. & Douglas, P.S. (2013). Use of stress testing and diagnostic catheterization after coronary stenting: association of site-level patterns with patient characteristics and outcomes in 247,052 Medicare beneficiaries. Journal of the American College of Cardiology 62 (5) 439-446.

Clough, J.D., Rajkumar, R., Crim, M.T., Ott, L.S., Desai, N.R., Conway, P.H., Maresh, S., Kahvecioglu, D.C. & Krumholz, H.M. (2016). Practice-Level Variation in Outpatient Cardiac Care and Association With Outcomes. Journal of the American Heart Association 5 (2) pii: e002594.

Eddy, D.M. (1984). Variations in physician practice: the role of uncertainty. Health Affairs (Millwood) 3 (2) 74-89.

Wennberg, J.E. (1984). Dealing with medical practice variations: a proposal for action. Health Affairs (Millwood) 3 (2) 6-32.

Grytten, J. & Sorensen, R. (2003). Practice variation and physician-specific effects. Journal of Health Economics 22 (3) 403-418.

Epstein, A.J. & Nicholson, S. (2009). The formation and evolution of physician treatment styles: an application to cesarean sections. Journal of Health Economics 28 (6) 1126-1140.

Feufel, M.A. (2018). How to Uncover Sources of Unwarranted Practice Variation: A Case Study in Emergency Medicine. Qualitative Health Research 28 (9) 1486-1498.

Khullar, D., Chokshi, D.A., Kocher, R., Reddy, A., Basu, K., Conway, P.H. & Rajkumar, R. (2015). Behavioral Economics and Physician Compensation - Promise and Challenges. New England Journal of Medicine 372 (24) 2281-2283.

Levinson, W., Kallewaard, M., Bhatia, R.S., Wolfson, D., Shortt, S. & Kerr, E.A. (2015). ‘Choosing Wisely’: a growing international campaign. BMJ Quality & Safety 24 (2) 167-174.

Willson, A. (2015). The problem with eliminating 'low-value care'. BMJ Quality & Safety 24 (10) 611-614.

de Vries, E.F., Struijs, J.N., Heijink, R., Hendrikx, R.J. & Baan, C.A. (2016). Are low-value care measures up to the task? A systematic review of the literature. BMC Health Services Research 16 (1) 405.

Rosenberg, A., Agiro, A., Gottlieb, M., Barron, J., Brady, P., Liu, Y., Li, C. & DeVries, A. (2015). Early trends among seven recommendations from the choosing wisely campaign. JAMA Internal Medicine 175 (12) 1913-1920.

Chandra, K., Atkinson, P.R., Fraser, J., Chatur, H. & Adams, C. (2017). MP31: The contrarian effect: how does a Choosing Wisely focused knowledge translation initiative affect emergency physician practice in a high awareness-low investigation environment? Canadian Journal of Emergency Medicine 19 (Supplement 1) S75-S76.

Manja, V. Monterio, S., Guyatt, G., You, J., Lakshminrusimha, S. & Jack, S. (2018). Understanding the factors that influence clinical decision-making- a sequential explanatory mixed methods study protocol. European Journal for Person Centered Healthcare 6 (2) 329-338.

Hockey, P.M. & Marshall, M.N. (2009). Doctors and quality improvement. Journal of the Royal Society of Medicine 102 (5) 173-176.

WHO. (2006). Quality of Care: A Process for Making Strategic Choices in Health Systems. Geneva: World Health Organization.

Tzelepis, F., Sanson-Fisher, R.W., Zucca, A.C. & Fradgley, E.A. (2015). Measuring the quality of patient-centered care: why patient-reported measures are critical to reliable assessment. Patient Preference and Adherence 9, 831-835.

Committee on Quality of Health Care in America & Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academies Press.

Neuman, M.D., Speck, R.M., Karlawish, J.H., Schwartz, J.S. & Shea, J.A. (2010). Hospital Protocols for the Inpatient Care of Older Adults: Results from a Statewide Survey. Journal of the American Geriatrics Society 58 (10) 1959-1964.

Studdert, D.M., Mello, M.M., Sage, W.M., DesRoches, C.M., Peugh, J., Zapert, K. & Brennan, T.A. (2005). Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. Journal of the American Medical Association 293 (21) 2609-2617.

Salloch, S., Otte, I., Reinacher‐Schick, A. & Vollmann, J. (2018). What does physicians' clinical expertise contribute to oncologic decision‐making? A qualitative interview study. Journal of Evaluation in Clinical Practice 24 (1) 180-186.

Brandt Vegas, D., Levinson, W., Norman, G., Monteiro, S. & You, J.J. (2015). Readiness of hospital-based internists to embrace and discuss high-value care with patients and family members: a single-centre cross-sectional survey study. CMAJ Open 3 (4) E382-386.

Bachmann, L.M., Mühleisen, A., Bock, A., ter Riet, G., Held, U. & Kessels, A.G.H. (2008). Vignette studies of medical choice and judgement to study caregivers' medical decision behaviour: systematic review. BMC Medical Research Methodology 8 (1) 50.

Veloski, J., Tai, S., Evans, A.S. & Nash, D.B. (2005). Clinical vignette-based surveys: a tool for assessing physician practice variation. American Journal of Medical Quality 20 (3) 151-157.

Epstein, A.E., DiMarco, J.P., Ellenbogen, K.A., et al. (2013). 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology 61 (3) e6-75.

Mendu, M.L., McAvay, G., Lampert, R., Stoehr, J. & Tinetti, M.E. (2009). Yield of diagnostic tests in evaluating syncopal episodes in older patients. Archives of Internal Medicine 169 (14) 1299-1305.

IBM. (2016). Available at:

Norman, G. (2010). Likert scales, levels of measurement and the "laws" of statistics. Advances in Health Sciences Education: Theory and Practice 15 (5) 625-632.

Hsieh, H.F. & Shannon, S.E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research 15 (9) 1277-1288.

Elo, S. & Kyngäs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing 62 (1) 107-115.

McCarthy, C.P., Vaduganathan, M. & Januzzi, J.L., Jr. (2018). Type 2 myocardial infarction - diagnosis, prognosis, and treatment. Journal of the American Medical Association doi: 10.1001/jama.2018.7125.

Epstein, A.E., DiMarco, J.P., Ellenbogen, K.A. et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Journal of the American College of Cardiology 51 (21) e1-62.

Shen, W.K., Sheldon, R.S., Benditt, D.G. et al. (2017). 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. Journal of the American College of Cardiology 70 (5) 620-663.

University of Utah Health. (2017). Bringing Value into Focus - The State Value in US Healthcare. Salt Lake City: University of Utah.

Tilburt, J.C., Wynia, M.K., Sheeler, R.D., Thorsteinsdottir, B., James, K.M., Egginton, J.S., Liebow, M., Hurst, S., Danis, M. & Goold, S.D. (2013). Views of US physicians about controlling health care costs. Journal of the American Medical Association 310 (4) 380-388.

Martin, A.B., Hartman, M., Benson, J. & Catlin, A. (2016). National Health Spending In 2014: Faster Growth Driven By Coverage Expansion And Prescription Drug Spending. Health Affairs (Millwood) 35 (1) 150-160.

Hartman, M., Martin, A.B., Espinosa, N., Catlin, A. & The National Health Expenditure Accounts Team. (2018). National Health Care Spending In 2016: Spending And Enrollment Growth Slow After Initial Coverage Expansions. Health Affairs (Millwood) 37 (1) 150-160.

Schneider, E.C., Sarnak, D.O., Squires, D., Shah, A. & Doty, M.M. (2017). Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care. Available at:

Institute of Medicine; Committee on the Learning Health Care System in America, McGinnis, J.M., Stuckhardt, L., Saunders, R. & Smith, M. (2013). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington DC: National Academies Press.

Anderson, J.L., Heidenreich, P.A., Barnett, P.G. et al. (2014). ACC/AHA Statement on Cost/Value Methodology in Clinical Practice Guidelines and Performance Measures. A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. Journal of the American College of Cardiology 63 (21) 2304-2322.

Fonseca, R., Jose, K. & Marwick, T.H. (2018). Understanding decision-making in cardiac imaging: determinants of appropriate use. European Heart Journal - Cardiovascular Imaging 19 (3) 262-268.

Farmer, S.A., Moghtaderi, A., Schilsky, S., Magid, D., Sage, W., Allen, N., Masoudi, F.A., Dor, A. & Black, B. (2018). Association of medical liability reform with clinician approach to coronary artery disease management. JAMA Cardiology doi: 10.1001/jamacardio.2018.1360.

Brooker, J.A., Hastings, J.W., Major-Monfried, H., Maron, C.P., Winkel, M., Wijeratine, H.R., Fleischman, W., Weingart, S. & Newman, D.H. (2015). The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates. Academic Emergency Medicine 22 (7) 883-886.

Keeter, S., Hatley, N., Kennedy, C. & Lau, A. (2017). What Low Response Rates Mean for Telephone Surveys. Available at:

Asch, D.A., Jedrziewski, M.K. & Christakis, N.A. (1997). Response rates to mail surveys published in medical journals. Journal of Clinical Epidemiology 50 (10) 1129-1136.

Peabody, J.W., Luck, J., Glassman, P., Jain, S., Hansen, J., Spell, M. & Lee, M. (2004). Measuring the quality of physician practice by using clinical vignettes: A prospective validation study. Annals of Internal Medicine 141 (10) 771-780.

Rutten, G.M., Harting, J., Rutten, S.T., Bekkering, G.E. & Kremers, S.P. (2006). Measuring physiotherapists’ guideline adherence by means of clinical vignettes: a validation study. Journal of Evaluation in Clinical Practice 12 (5) 491-500.



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