'Internal Competitiveness' of Docs Spurs Improvement

Nick Mulcahy

November 12, 2020

It seems like a small thing, but oncologists often don't do it ― enter the stage of a patient's cancer in a field or box in an electronic healthcare record (EHR).

"The physicians know their patients' stage of disease," commented Anna Sinaiko, PhD, of the Harvard T. H. Chan School of Public Health in Boston, Massachusetts. But this information is frequently buried in the narrative of an EHR clinical note and so cannot be tallied digitally.

That's a problem, because stage is used, for example, to identify patients who are eligible for clinical trials or in need of multimodality care or other services from an institution/practice.

So, documenting the stage in the correct box in the EHR could improve patient care. But it involves a few additional clicks beyond note writing and, for many clinicians, a change in the way they currently document, Sinaiko noted.

Could oncologists improve their performance of this sometimes neglected but important task? Working with a team of colleagues at Massachusetts General Hospital (MGH), investigators set out to motivate oncologists by showing them how they compare with their peers on this task.

"We leveraged the internal competitiveness that people have," Sinaiko explained. "You want to improve and not be at the bottom [of performance in your peer group]."

The researchers devised a study that involved 56 oncologists at MGH. Half of them received up to three emails over 6 months that displayed the individual's rate of proper documentation of disease stage in comparison with that of the whole group. The other half did not receive these emails.

Each email included 56 bar charts reflecting cancer stage documentation ― one bar for each doctor (notably, the graphic was anonymous, with no physician names). Only 10% of the group were identified as "top performers"; everyone else was left to improve.

The approach worked: receipt of emails (vs no email ― and thus no peer comparison) was associated with increased likelihood of proper documentation of cancer stage (23.2% vs 13.0% of patient index visits).

That absolute increase of 9% was statistically significant (P = .002) and was a "substantial" improvement, the authors comment.

The study was published online October 6 in JAMA Network Open.

The results represent a "meaningful" change in clinical practice, says Amol Navathe, MD, PhD, practicing clinician and senior fellow, Leonard Davis Institute for Health Economics at the University of Pennsylvania, Philadelphia, Pennsylvania.

"Getting physicians to change their prevalent practices and work flow is always hard," he told Medscape Medical News, "because there are so many competing demands."

Study Avoided Comparison to the Median

The emails sent to oncologists at MGH's Cancer Center ― and similar interventions conducted elsewhere ― likely trigger a "visceral response" from clinicians, Navathe believes.

"In medical training, there are such strong professional standards. And deviation from the norm is not considered a good thing," he said.

Navathe also stressed the importance of the anonymous bar chart rankings in the MGH emails. "The emails were like a psychological intervention, which require careful use," he says.

There is growing evidence that providing physicians with peer comparisons can help change medical practice patterns, say both Navathe and Sinaiko. Most of the studies have focused on the writing of prescriptions, especially for antibiotics.

A variety of entities now rate physicians, observes Navathe.

For example, there are public ratings of doctors on tech platforms such as Yelp and Healthgrades. Both have the potential to annoy physicians via negative reviews, which are "highly subjective," he says.

Those public ratings have also influenced private healthcare's disclosures of physician data, he adds.

In an essay in Harvard Business Review last year, Navathe and two coauthors point out that in 2008, Utah Health started collecting patient feedback and sharing it with physicians (it also revealed how individual doctors compared with anonymous peers). By 2012, the presence of websites such Healthgrades prompted Utah Health to start publicly posting patient feedback and scores for its individual physicians on its website. Notably, scores for 25% of their physicians exceeded the 99th percentile compared to peers nationwide, points out Navathe, suggesting that this intervention spurred excellence.

Some circumstances are better suited for data comparisons of doctors, Navathe believes.

"Peer comparisons are likely most useful when applied to clinical decisions with clear choices and when performance metrics have been accepted by physicians," he and a coauthor wrote in a 2016 essay in JAMA.

However, comparisons are also tricky and should be designed carefully, Navathe says. A physician ratings initiative can boomerang and demotivate people if they feel like "big brother" is upon them.

When institutions conduct an intervention using peer comparisons to change practice, the physicians should have input, he says.

"Clinicians need to feel that something is being done with them, not to them," Navathe emphasizes.

In the end, doctors are competitive strivers, suggest the study authors.

They emphasize that they showed oncologists their own individual-level data relative to the top performers ― as opposed to the mean and median levels of performance. "Peer comparison interventions that use this latter design may not be as effective," they say, citing a 2017 study.

Sinaiko further characterized that competitiveness: "[It's] where you just want to be better, you want to improve and not be at the bottom ― for its own sake, because you think it's important."

The authors and Navathe have disclosed no relevant financial relationships.

JAMA Netw Open. Published online October 6, 2020. Full text

Nick Mulcahy is an award-winning senior journalist for Medscape. He previously freelanced for HealthDay and MedPageToday and had bylines in WashingtonPost.com, MSNBC, and Yahoo. Email: nmulcahy@medscape.net and on Twitter: @MulcahyNick.

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