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Medical Decision Making
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Diagnostic Certainty as a Source of Medical Practice Variation in Coronary Heart Disease: Results from a Cross-National Experiment of Clinical Decision Making

Karen E. Lutfey, PhD

New England Research Institutes, Watertown, Massachusetts, klutfey{at}neriscience.com

Carol L. Link, PhD

New England Research Institutes, Watertown, Massachusetts

Lisa D. Marceau, MPH

New England Research Institutes, Watertown, Massachusetts

Richard W. Grant, MD, MPH

Massachusetts General Hospital and Harvard Medical School, Boston

Ann Adams, PhD

University of Warwick, Coventry, UK

Sara Arber, PhD

University of Surrey, Guildford, UK

Johannes Siegrist, PhD

Dusseldorf University, Dusseldorf, Germany (JS); and University of Hamburg, Hamburg, Germany

Markus Bönte, MA

New England Research Institutes, Watertown, Massachusetts

Olaf von dem Knesebeck, PhD

New England Research Institutes, Watertown, Massachusetts

John B. McKinlay, PhD

New England Research Institutes, Watertown, Massachusetts

The authors examined physician diagnostic certainty as one reason for cross-national medical practice variation. Data are from a factorial experiment conducted in the United States, the United Kingdom, and Germany, estimating 384 generalist physicians’ diagnostic and treatment decisions for videotaped vignettes of actor patients depicting a presentation consistent with coronary heart disease (CHD). Despite identical vignette presentations, the authors observed significant differences across health care systems, with US physicians being the most certain and German physicians the least certain (P < 0.0001). Physicians were least certain of a CHD diagnoses when patients were younger and female (P < 0.0086), and there was additional variation by health care system (as represented by country) depending on patient age (P < 0.0100) and race (P < 0.0021). Certainty was positively correlated with several clinical actions, including test ordering, prescriptions, referrals to specialists, and time to follow-up.

Key Words: clinical decision making • medical practice variation • health disparities.

This version was published on September 1, 2009

Medical Decision Making, Vol. 29, No. 5, 606-618 (2009)
DOI: 10.1177/0272989X09331811
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