Geographic hierarchies of diagnostic practice style in cerebrovascular disease

Diagnostic practice style describes the ways in which physicians diagnose information about disease. Like practice style effects in general, diagnostic practice style effects may emerge as the result of training, inter-personal relationships between professionals, medical enthusiasm for particular diagnoses and patient-physician interactions. In this study we analyze the ways in which patterns of diagnostic practice style associated with cerebrovascular disease varies at different socio-geographical scales in the province of Alberta, Canada. We use hierarchical linear models to partition a measure of diagnostic practice style into four levels of observation: the physician level, the facility level, the municipality level and the regional (census division) level. We model a variety of fixed effects related to physician attributes, their practice, the facilities they work in and the municipalities within which their facilities operate. Our results suggest that attributes related to physicians and the facilities and municipalities in which they work all contribute to patterns of diagnostic practice style. Physicians working in rural and urban municipalities have different practice style patterns even after controlling for the types of facilities they work in, their professional medical specialization and their workload. Similar to other research, our results reveal that physicians have different diagnostic practice styles with members of the same sex than members of the opposite sex. Geographic variations in diagnostic practice style may obscure changes in the epidemiology of cerebrovascular disease in rural communities, and provide indirect evidence that the quality and/or timeliness of diagnosis may be worse in rural Alberta.