Specialists Tend to Order More Tests, Drugs, Study Finds

Medical specialists are more likely than general practitioners to prescribe drugs, conduct tests, hospitalize patients and do other expensive procedures, even when one takes into account differences in their patients’ health and age, new research suggests.

The findings, by researchers at the RAND Corp., UCLA and elsewhere, may shed light on a source of controllable costs within the health-care system--at a time when most young doctors opt to become higher-paid specialists rather than generalists.

“This is a nation of specialty practitioners,” said Dr. Richard L. Kravitz, a UCLA assistant professor and co-author of the papers published today in the Journal of the American Medical Assn. “That appears to be a more expensive version of care.”

It has long been unclear whether specialists were genuinely more lavish in their care or whether their patients were just sicker and needed more aggressive treatment. For the first time, the researchers found a way of controlling for differences in so-called patient mix.

Using that technique, they found not only that specialists were more aggressive but also that doctors in solo and small practices were more inclined to hospitalize, test and prescribe than were physicians in multi-specialty groups and health maintenance organizations (HMOs).

Styles of practice were also influenced by the way in which the patient’s bill was to be paid: Doctors were less likely to hospitalize patients who were part of prepaid group plans than patients whose bills were to be covered on a fee-for-service basis.

“It’s like you have an allowance,” said Dr. Sheldon Greenfield, a professor of medicine at Tufts University and a co-author of the papers. “If your mom gives you an allowance, you’re likely to spend less than if she gives you money whenever you ask for it.”

It is not yet clear, however, whether the greater use of health-care resources by specialists documented in the study has any effect, positive or negative, on the quality of patients’ care. The researchers will address that question next.

In the study, the researchers analyzed the cases of 20,158 adults who visited physicians’ offices during a nine-day period in 1986. The doctors involved were 349 physicians in family medicine, internal medicine, endocrinology and cardiology.

The group found that, indeed, different practices attract different patients: Cardiologists got older, sicker patients with more chronic conditions; family practitioners got younger, more “functional” patients with fewer chronic conditions.

But when the researchers controlled for those differences, they found that doctors’ inclination to hospitalize, prescribe drugs and conduct tests was still influenced by whether they were generalists or specialists, where they practiced and how they were paid.

Cardiologists hospitalized patients at more than twice the rate of family practitioners; the rate for endocrinologists was 50% greater. Endocrinologists, who treat such conditions as thyroid disease and diabetes, had significantly higher rates of office visits than those of the other three groups.

Physicians working in large, multi-specialty practices and HMOs were the least likely to hospitalize their patients.