Physicians’ Construction of Quality

In this section, two aspects of physicians’ conception of quality in health care delivery are addressed. First, the results of the two empirical projects are

compared, and second, disagreement between the findings and prior research are discussed.

Table 1-5 Comparison of quality constructs between Project Two and Three

Element Construct P2 P3 Theory Theoretical concept

Reference example

Process Communication X X TPB Attitude Ajzen 1991, p. 198 Agency Risk: monitoring and

negotiation Conlon & Parks 1990, p.

607 Correct

interpretation of information

X TPB Control belief Ajzen 1991, p. 204

Decision Causal vs. diagnostic

interpretation Einhorn & Hogarth 1981, p. 65

Agency Moral hazard &

adverse selection

Conlon & Parks 1990, p.

619; Eisenhart 1989, p.

Agency Moral hazard &

adverse selection

Agency Adverse selection Eisenhart 1989, p. 61 Decision Habit persistence Ajzen 1989, p. 203 Standards of

care

X Decision Causal vs. diagnostic interpretation

Einhorn & Hogarth 1981, p. 65

Evaluation X Decision Reinforcement: positive outcome feedback

Agency Risk: random market effect

Conlon & Parks 1990, p.

610

1.9.4.1 Comparison of Empirical Findings

There is a close relation between influencers (enablers and barriers) and quality constructs. The level of investigation in both empirical projects is the patient-physician encounter, based on real patient cases supplied by patient-physicians taking part in the study. Thus, physicians’ conception of quality is linked with actual clinical practice, and the findings in Project Two and Three are homogenous; see Error! Reference source not found.. Two notable differences emerged when comparing constructs of physicians’ quality conception between the two empirical projects. First, the patient was found to be a construct in Project Three, but not in Project Two. The patient construct appeared in Project Two, but did not reach significance as per the study protocol. This was not the case in Project Three.

of this topic being predefined for investigation in the protocol; see Appendix C.1.13 Interview Guide on page 377.

1.9.4.2 Contradictory Findings

Quality evidence of studies examining physicians’ conception of quality has not been reported in the extant literature. The constructs have previously been addressed separately, but not in the context of how physicians frame quality in health care delivery. Theoretical saturation was achieved early, at interview 17 in this study. It is therefore reasonable to argue that the emerging constructs reflect that there is strong agreement within the physician community about what constitutes quality in health care, which is embedded in the “medical institution”

and practice. However, the findings are in disagreement with previous studies, on three points. First, the findings of cooperation and organization are not in line with Agency Theory. The findings of the study focus on interpersonal cooperative efforts between health care professionals rather than the presumed patient-physician dyad of Agency Theory (patient-physician agency, see Section 1.9.4.2.1).

Second, physicians claim that experience is a construct and a strong influencer;

however, literature is divided on whether more experienced physicians translate their experience into better quality of care. Third, in this study physicians unanimously claim that resources are lacking and that quality of care suffers as a consequence, but empirical studies do not support this claim. These findings are now discussed in more detail.

1.9.4.2.1 Agency

Delivery of health care in the context of modern medicine may be considered a cooperative effort. According to Eisenhardt (1989) p. 72, “Agency Theory provides a unique, realistic and empirically testable perspective on problems of cooperative effort”. Thus, the principal-agent dyad may be considered a cooperative effort. The main tenet of Agency Theory holds that there is a conflict of interest between the principal and the agent. On one hand, asymmetry of information may drive a condition of moral hazard, and on the other, risk may cause adverse selection to occur. Even though the findings of this study support patient-physician cooperation, the main focus is on the quality of the cooperative effort among physicians and other health care workers. In this context, economic interest would drive a possible conflict of interest. However, this is not felt to be the case in this study due to the lack of evidence in support of this notion.

The findings of this study suggest that how health care service delivery is organized may influence quality in health care. Physicians claim that health care service delivery should be organized so that patients have equal access, should ensure efficient and appropriate cooperation between different health care professionals providing health care according to standardised protocols, and should ensure a supportive work environment.

1.9.4.2.2 Experience

Experience emerged as a construct of physicians’ conception of quality, and the respondents claim that more experienced physicians are more likely to provide

that “physicians who have been in practice longer may be at risk for providing lower-quality care” (Choudhry et al., 2005 p. 260). Thus, the findings in this study and that in the literature are contradictory.

There may be several explanations for this finding. First, the physicians’ “toolkits”

are created during training and may not be updated regularly (Carthy et al., 2000).

Second, older physicians seem less likely to adopt newly proven therapies, and may be less receptive to new standards of care (Choudhry et al., 2005). In addition, practice innovations that involve theoretical shifts, such as the use of less invasive medical interventions (i.e., laparoscopic versus open surgical techniques), may take longer to adopt due to habit persistence (Coleman et al., 1957, Coleman et al., 1959, Menzel and Katz, 1955, Kwong and Norton, 2007).

However, when it comes to treating a particular disease, experience is an important indicator of quality. Studies show that physicians/hospitals that treat a high number of patients for a particular disease and perform large numbers of procedures to treat it have better results (Birkmeyer et al., 2002). Thus, consensus on the effect of experience on quality in the literature is therefore lacking. The literature points in two directions when it comes to experience. First, a body of evidence investigates experience at the physician level, measured by time in practice, and finds a paradoxical effect. Second, a body of evidence has examined experience in relation to specific disease and procedures, and found that higher numbers of patients treated reduces mortality. This may indicate that years in practice as a measure of experience is an inaccurate measure of experience.

1.9.4.2.3 Resources

In this study, physicians claim that increased resource availability and utilization will improve clinical outcomes. However, there is little evidence in the literature suggesting that increased resource utilization improves outcomes (Wennberg et al., 2002). Fisher et al. (2003) investigated whether regions with higher Medicare spending provide better care. The authors found that regional differences in Medicare spending are largely explained by the more inpatient-based and specialist oriented pattern of practice observed in high-spending regions, and that neither quality of care nor access to care appear to be better for Medicare enrolees in higher-spending regions (Fisher et al., 2003 p. 273). Furthermore,

“Medicare enrolees in higher-spending regions receive more care than those in lower-spending regions, but do not have better health outcomes or satisfaction with care” (Fisher et al., 2003 p. 288).