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C. BARBER MUELLER,t MD, FRCS[C]. BARBARA YAFFE,* MD. Hypothetical clinical cases were used to investigate surgical decision-making in relation to ...
Measuring surgical decision-making with hypothetical cases

Hypothetical clinical cases were used to investigate surgical decision-making in relation to surgical rates across Ontario. Six procedures were studied (cholecystectomy, colectomy, inguinal herniorrhaphy, hysterectomy, cesarean section and tonsillectomy-adenoidectomy), and substantial differences of opinion regarding the choice of surgical or nonsurgical treatment were recorded. The decision to operate, however, was not made more frequently in Ontario counties with high operative rates, and none of the demographic variables studied were correlated with the decision to operate. Other variables that might have affected operative rates were not taken into account. There were also differences of opinion in referral decisions, but generally internists and pediatricians were less likely to refer the hypothetical cases to surgeons than were family physicians. Des cas cliniques hypothbtiques ont At utilis6s afin d'6tudier les rapports entre la prise de d6cision d'op6rer et la frAquence des interventions chirurgicales A travers l'Ontario. Six interventions furent Atudi6es (chol6cystectomie, colectomie, herniorraphie inguinale, hyst6rectomie, cAsarienne et amygdalectomie-ad6noidectomie), et des diff6rences marqubes d'opinion ont 6t enregistr6es en ce qui concerne le choix d'un traitement chirurgical ou non chirurgical. Toutefois, la dbcision d'op6rer n'a pas At prise plus frbquemment dans les comt6s ontariens poss6dant un taux 6lev6 d'interventions chirurgicales, et aucun des facteurs d6mographiques btudi6s n'a montr6 de corrAlation avec la d6cision d'op6rer. Les autres facteurs ayant pu influencer le taux des interventions n'ont pas AtA consid6rAs. On a aussi observA des diff6rences d'opinion en ce qui a trait A la dAcision d'envoyer un patient en consultation, mais, de fagon gbnbrale, les internistes et les pAdiatres 6taient moins enclins A diriger les cas hypothAtiques chez un consultant que ne l'taient les mAdecins de famille.

The counties of Ontario show persistent and substantial variation in their age- and sex-adjusted surgical rates,'2 and the physician's decision on whether to operate may be partly responsible. To investigate the relation of From *the department of health administration, faculty of medicine, University of Toronto, and tthe department of surgery, faculty of medicine, McMaster University, Hamilton, Ont. Adapted from a presentation at the 50th Annual Meeting of the Royal College of Physicians and Surgeons of Canada, Toronto, Sept. 17, 1981

Reprint requests to: Dr. Eugene Vayda, Associate dean, community health, Faculty of medicine, 1st floor, McMurrich Building, University of Toronto, Toronto, Ont. M5S 1A8

EUGENE VAYDA,* MD, FRCP[C] WILLIAM R. MINDELL,* MPH C. BARBER MUELLER,t MD, FRCS[C] BARBARA YAFFE,* MD surgical decision-making to county rankings, clinical case histories and questionnaires were sent to surgeons and referring physicians in counties with high and low rates. This format also allowed us to assess the level of agreement in each hypothetical case and to look for associations between the decision to operate and the sociodemographic and practice variables of the physicians. Other studies have demonstrated variation in surgical rates in lafge and small political and geographic subdivisions.3`9 Resources such as hospital beds, surgical personnel, money spent on health care and fee-for-service payments have been associated with the amount of surgery done. Variation in rates has also been attributed to the decision-making of surgeons: treatment styles vary, there is disagreement regarding indications, and the relative efficacy of many surgical and nonsurgical treatments is not well established.'0 Studies on the quality of care have attempted to measure physician performance by matching patient records with standards of practice set by peers. A review of hysterectomies in Saskatchewan, for instance, resulted in the classification of 23.7% of the operations as unjustified; this proportion fell to 7.8% following the audit." The classification of an operation as unjustified may have been made through disagreement about indications. Studies in the United States found that a second surgeon reversed the decision to operate in approximately 25% of patients.'2 Hypothetical cases, or patient management problems, are one means of studying decision-making in medicine and surgery, although such simulations of clinical situations have been used primarily for teaching purposes. Responses to written patient management problems have not been consistently correlated with actual clinical performance.'3 Because there is no doctor-patient contact and no assurance that physicians actually do what they say they would do, the cases really measure technical judgements. Rutkow and associates,'4 using hypothetical cases, found considerable differences of opinion among surgeons and could not correlate the decision to recommend surgery with variables of practice or sociodemography. This study uses hypothetical cases to measure the level of agreement or disagreement in the technical decision to refer or operate and to determine whether those decisions were made more frequently in selected Ontario counties with high operative rates.

Methods We selected five primarily discretionary operations (cholecystectomy, inguinal herniorrhaphy, hysterectoCMA JOURNAL/AUGUST 15, 1982/VOL. 127 287

my, cesarean section and tonsillectomy-adenoidectomy) and a sixth, colectomy, for which there is little choice. For each operation we prepared several hypothetical cases with the intent that there would be a clear consensus for or against surgery in one or two of them

(control cases) and disagreement about the rest (test cases). Our hypothetical cases were modified extensively after review by a number of clinicians. Surgeons were asked whether they would operate in these cases; we asked referring physicians whether surgery was called for, and, if so, whether they themselves would operate or instead refer to a specialist. Referrals were to be differentiated into those for which surgery was requested and those for which only an opinion was sought. The option of referral to an internist or a pediatrician was not available to family physician respondents. Through a questionnaire accompanying the hypothetical cases we also investigated the associations of practice-related and sociodemographic variables with the decision to operate. In a pilot study we sent our cases and questionnaire to physicians in just one county in order to estimate response rates, test the face validity of the cases and make an initial determination of agreement and disagreement. The response rate was 70%, and our division of the cases into control and test cases was confirmed.'5 Control cases were those in which agreement was at least 80%. Three quarters of the respondents indicated the cases were typical of those seen in their practices. Twelve Ontario counties were selected for a full-scale study in 1980; six had generally high age- and sexstandardized rates and six generally low rates for the operations being studied over a 5-year period, 1973 to 1977. The two groups of counties were matched for Tesources (hospital beds and physicians) to minimize the effect of these variables. Three cases were used for cesarean section and four for each of the other procedures. Cholecystectomy, colectomy and inguinal herniorrhaphy cases were sent to a 62% stratified random sample (SRS) of general surgeons (109 of 176) and a 30% SRS of internists (74 of 245). Stratification, when employed, was on the basis of physician specialty and ranking of the county as high or low for the operation under study. Hysterectomy and cesarean section cases were mailed to all 98 obstetrician-gynecologists. Tonsillectomy-adenoidectomy cases were directed to all otolaryngologists (46) -and a 66% SRS of pediatricians (65 of 99). All cases except cesarean section were sent to a 16% SRS of certified and noncertified family physicians (257 of 1602). The tonsillectomy-adenoidectomy cases were also sent to 40 family physicians (35% SRS) in two additional counties, one with high and the other with low age- and sex-standardized rates for that operation. Findings Response rates The

case and

questionnaire sets

were

sent to

689

surgeons and referring physicians in the 14 counties. After 78 physicians who were deceased or had retired, 288 CMA JOURNAL/AUGUST 15, 1982/VOL. 127

moved or never practised their specialty in the county were removed from the sample, a final response rate of 68% (417) was obtained. It varied from 60% for family physicians to 77% for general surgeons and 79% for pediatricians and obstetrician-gynecologists. No statistically significant differences between the characteristics of the respondents and nonrespondents (age, sex, country of graduation, years in practice and type of practice) were found, except that certificants of the College of Family Physicians of Canada had a significantly higher response rate than noncertificants (88% v. 53%; x2 = 17.4; P < 0.001). Of all those responding 77% indicated that the hypothetical cases were representative of cases encountered in their practices (90% of the surgeons, 88% of family physicians and 68% of internists).

The decision to operate

Substantial differences of opinion among surgeons were recorded (Table I). Our initial designation of control and test cases was confirmed, except for colectomy, for which all four cases now seemed to have been test cases. There was also less agreement than expected for the hysterectomy surgical control case and the cholecystectomy nonsurgical control case. Since family physicians were first asked whether they would operate themselves, we have some indication of the extent to which this group does surgery (Table II). Table I-Surgeons' responses to hypothetical cases

Operation

Proportion choosing surgery (%) Test cases* Control cases* Surgery Surgery expected not expected 1 2 3 4 94 23 42 20 30 54 29 47

(no. of respondents) Cholecystectomy (71) Colectomy (64) Inguinal 85 herniorrhaphy (70) 77 Hysterectomy (73) 4 Cesarean section (74) Tonsillectomy11 96 adenoidectomy (28) *There were not enough cases to fill every category.

70 43 35

57 47 30

78 25

-

-

-

29

46

-

-

-

Table Il-Family physicians' choice of surgery in hypothetical cases Proportion who would themselves operate (%) Test cases* Control cases*

Operation

(no. of respondents)

Cholecystectomy (126) Colectomy (124) Inguinal herniorrhaphy (126) Hysterectomy (127) Tonsillectomy-

Surgery

Surgery

14

5

-

15

3

4

0

2 4

-

-

-

4

2

4

8

-

14

7

10

-

10

13

11

-

29

46

expected not expected 1

11

9 28 adenoidectomy (152) *There were not enough cases to fill every category.

Percentages ranged from 8 for colectomy to 28 for tonsil surgery. No correlations between the decisions to operate and the overall high and low county rankings were demonstrated; generally speaking, surgeons in counties with high rates were not more likely to opt for surgical treatment. In one hysterectomy test case obstetrician-gynecologists who had done fewer than 10 of the operations in the previous 6 months were significantly less likely to choose surgery than those who had done more than 10 operations (P < 0.05). This was the only one of the 23 hypothetical cases in which the volume of surgery was associated with the decision to operate. Referral patterns

Family physicians, internists and pediatricians disagreed regarding the decision to refer (Table III) and whether referral should be for surgery or an opinion. Differences between family physicians and specialists were also found. For the cholecystectomy and colectomy cases family physicians were consistently more likely to opt for surgical referral than were internists. However, among the internists and family physicians who opted for referral, the proportions seeking surgery or an opinion were the same. For the hernia cases the referral patterns of the family physicians and internists were also similar. Pediatricians were 25% to 50% less likely than family physicians to refer the four tonsillectomy-adenoidectomy cases (P > 0.05 in each case) and when they did so they were seeking an opinion rather than surgery. Referral decisions by family physicians were also compared on the basis of certification. For 5 of 20 cases noncertificants were significantly more likely (P < 0.05) to make a referral to a surgeon, and in 2 other cases such referral was significantly more likely to be for surgery than for an opinion. Correlations with practice and sociodemographic variables Of the general surgeons 82% elected to operate in five Table Ill-Referring physicians' responses to hypothetical cases

Operation and

type of physician (no.) Cholecystectomy Family physicians (126) Internists (44)

Proportion referring cases Test cases* Control cases* Surgery Surgery expected not expected 1 2 3 4 93 80

44 13

67 32

75

-

-

41

-

-

69 47

74 64

61 49

71 42

88 98

52 36

79 79

-

75 54

57 26

-

-

-

-

Colectomy Family physicians (124) Internists (43)

-

-

-

-

Inguinal herniorrhaphy Family physicians (126) Internists (43)

86 95

-

Tonsillectomy-adenoidectomy Family physicians (152)

-

97 46 Pediatricians (46) 74 28 *There were not enough cases to fill every category.

fewer of the nine test cases. For obstetriciangynecologists there were five test cases, and 77% chose surgical treatment in two or fewer of them. The surgeons who chose surgery in the cholecystectomy nonsurgical control case also opted for surgery in significantly more of the test cases than the surgeons who would not have operated in that one case (P = 0.02). Surgeons and obstetrician-gynecologists were then divided into two groups, one with a high and the other with a low likelihood of opting for surgical treatment. The grouping was done on the basis of the number of hypothetical cases in which each surgeon decided to operate, with each case weighted in inverse proportion to the number of surgeons choosing operative treatment. Six independent variables were studied: country of initial medical training, practice arrangements (solo, group etc.), decade of entry into practice, year of graduation from medical school, years in practice in the same Ontario county and numbers of operations performed in the previous 6 months. Each variable was dichotomized and individually examined against the two groups of physicians in two-by-two tables. For surgeons there were no statistically significant associations between any of the independent variables and the likelihood of selecting surgical treatment. For obstetrician-gynecologists several statistically significant (P < 0.05) associations were found. Those initially trained in Canadian or British medical schools were less likely to opt for surgery than their colleagues trained elsewhere. Also, if they had done fewer than 10 hysterectomies in the past 6 months they opted for surgery less frequently. Obstetrician-gynecologists in counties with university-based teaching centres and those in other than solo practice were significantly less likely to choose surgical treatment. Discussion This study has demonstrated substantial variation in the technical decision to operate, sometimes even when a consensus was expected. No consistent correlations between those decisions and the county surgical-rate rankings, the presence of university teaching centres or physician characteristics could be found. The disagreement detected among physicians in this and other studies may reflect the fact that the efficacy of surgical treatment has rarely been determined by randomized clinical trials. Until that is systematically done, disagreement can be expected. A 1973 study indicated that, for Ontario, nonspecialists did 32% of all tonsil surgery, 14% of hernia surgery, 6% of cholecystectomies and hysterectomies, and 2% of colectomies.'6 We found that as many as 10% to 15% of the family doctors surveyed opted at least once to do a cholecystectomy, an inguinal herniorrhaphy or a hysterectomy themselves; 28% would do a tonsillectomy and 8% a colectomy. While the numbers are too small to test statistical significance, it appears that most of the family physicians who opted to do the surgery were from rural counties or counties without university-

or

based health

science

centres. This is not surprising since

the choice in such places is frequently between surgery by the family physician and transport of the patient. CMA JOURNAL/AUGUST 15, 1982/VOL. 127

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Family physicians opting to do surgery themselves had on average, though, done fewer of the procedures in question in the preceding 6 months than the surgical specialists. Differences in referral patterns also appear to play a part in the nature of the treatment. Sometimes, as in gallbladder and colon surgery, the internists were much less likely to opt for surgical referral than were family physicians; pediatricians were less likely to refer for possible tonsil surgery. In a quarter of the cases certificants of the College of Family Physicians of Canada were significantly less likely to refer than their colleagues, although usually there was no difference between these groups. While controversy and disagreement are inevitable in the practice of medicine, these differences of opinion could be translated into different outcomes for a patient. In test case 2 (cholecystectomy), for instance, 75% of the family physicians opted for referral, while 42% of the surgeons chose to operate. The overall possibility of surgery was, then, 32%. Only 41% of internists chose to refer the same case, and since the proportion of surgeons who would operate remains the same, the possibility of surgery was reduced to 17%. Differences in the likelihood of a surgical outcome were also found in the tonsil cases when pediatricians and family physicians were compared. These findings suggest that seeing a nonsurgical specialist is less likely to lead to surgery than seeing a family doctor. However, the option of referral to an internist or pediatrician was not available to the family doctor; it should be included in subsequent studies. Perhaps the opinion of both nonsurgical and surgical specialists should be sought whenever primarily discretionary surgery is being considered. As well, secondopinion programs could be modified to include internists

In the

and pediatricians in addition to surgeons. The heir of the disagreement is, after all, the patient, whose choice of physician and surgeon very likely plays a part in whether surgical or nonsurgical treatment is selected. We thank Dr. Raisa Deber and Professor David Hewitt for statistical assistance, Mrs. Desiree Chanderbhan and Miss Stella Zegas for help in preparing the manuscript, and the Ontario surgeons and physicians who' responded to our questionnaire and made many helpful suggestions. This study was supported by a grant from the Physicians' Services Incorporated Foundation.

References I. STOCKWELL H, VAYDA E: Variations in surgery in Ontario. Med (are 1979; 7: 390-396 2. SHAH CP, CARR LM: Tonsillectomies: in dollars and cents. Can Med Assoc J 1974; 110: 301 -303 3. BUNKER JP: Surgical manpower: a comparison of operations and surgeons in the United States and in England and Wales. N Engi J Med 1970; 282: 135-144 4. VAYDA E: A comparison of surgical rates in Canada and in England and Wales. N Engi J Med 1973; 289: 1224-1229 5. BOMBARDIER C, FUCHS VR, LILLARD LA, WARNER KE: Socioeconomic factors affecting the utilization of surgical operations. N Engi J Med 1977; 297: 699-705 6. Roos NP, Roos LL: High and low surgical rates: risk factors for area residents. Am J

Public Health 1981; 71: 591-600 7. LEWIS CE: Variations in the incidence of surgery. N Engi J Med 1969; 281: 880-884 8. VAYDA E, MoRIsoN M, ANDERSON GD: Surgical rates in the Canadian provinces, 196810 1972. Can JSurg 1976; 19: 235-242 9. WENNBERG J, GITTELSOHN A: Small area variations in health care delivery. Science 1973; 182: 1l02-1108 10. BUNKER JP, MCPHERSON K, HENNEMAN P: Elective hysterectomy. In BUNKER JP, BARNES BA, MOSTELLER F (eds): Cost, Risks and Benefits of Surgery, Oxford U Pr, New York, 1977: 262-276 11. DYcK FJ, MURPHY FA, MURPHY JK, ROAD DA, BOYD MS. OSBORNE E, DE VLIEGER D, KORCHINSKI B, RIPLEY C, BROMLEY AT, INNES PB: Effect of surveillance on the number of hysterectomies in the province of Saskatchewan. N EngI J Med 1977; 296: 1326-1328 12. MCCARTHY EG, FINKEL ML: Second opinion elective surgery programs: outcome status over time. Med Care 1978; 16: 984-994 13. WILLtAMSON JW: Assessing clinical judgment. J Med Educ 1965; 40: 180-187 14. RUTKOw IM, GITTEI.SOHN AM, ZUIDEMA GD: Surgical decision making: the reliability of clinical judgment. Ann Surg 1979; 190: 409-417 15. VAYDA E, MINDELL WR, MUELLER CB: Use of hypothetical cases to investigate indications for surgery. (.an J Surg 1981; 24: 19-21 16. VAYDA E, LYONS D, ANDERSON GD: Surgery and anesthesia in Ontario. Can Med AssocJ 1977; 116: 263-1266

Intranasally administered phenylephrine Phenyleplirine has been used as a nasal decongestant and a mydriatic for next several decades; however, little is known about its systemic absorption and C1VIAJ cardiovascular effects. Drs. Myers and lazzetta therefore examined the possible pressor effect of phenylephrine in two groups of susceptible patients.

Caffeine elimination in late pregnancy Are the adverse effects of caffeine more common in pregnant women? What influence does caffeine, and its withdrawal, have on newborns? Drs. Parsons and Pelletier studied 15 women in the last 2 weeks of pregnancy to determine the effects of the delayed elimination of caffeine in such women.

Hospitat underfunding Medical writer Milan Korcok reports on his cross-country survey of underfunding in the health care system.

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