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Cost, uncertainty, and doctors' decisions. The case of thrombolytic therapy
1Section of General Internal Medicine, Seattle Veterans Affairs Medical Center, WA 98108.
Insights
Physicians often choose more expensive thrombolytic therapies for acute myocardial infarction based on surrogate endpoints, not proven benefits. Patient insurance and practice setting influence these critical treatment decisions.
Area of Science:
- Cardiology
- Pharmacology
- Health Services Research
Background:
- Acute myocardial infarction (AMI) treatment relies on timely reperfusion therapies.
- Intravenous thrombolytic agents are crucial for AMI management.
- Understanding physician prescribing patterns for thrombolytics is essential for optimizing patient care.
Purpose of the Study:
- To investigate the prescribing patterns of intravenous thrombolytic therapy for AMI.
- To identify predictors influencing cardiologists' choice between tissue plasminogen activator and streptokinase.
- To explore the impact of perceived efficacy, side effects, practice setting, and patient insurance on treatment selection.
Main Methods:
- A survey was conducted among 250 California cardiologists between July 1989 and February 1990.
- The survey focused on hypothetical treatment scenarios for uncomplicated acute anterior-wall myocardial infarction.
- Statistical analysis was used to determine the likelihood of choosing specific thrombolytic agents based on various factors.
Main Results:
- For a typical AMI case, 98% of cardiologists would use thrombolytics, with 79% preferring tissue plasminogen activator over streptokinase (21%).
- Physicians using tissue plasminogen activator were more likely to perceive it as superior for early recanalization, but perceived similar benefits for ejection fraction and mortality compared to streptokinase.
- Treatment choices were influenced by practice setting (health maintenance organization vs. others) and patient insurance status, with a notable willingness to switch to cheaper alternatives for uninsured or Medicaid patients.
Conclusions:
- Physician choices in thrombolytic therapy are heavily influenced by surrogate endpoints rather than established clinical outcomes.
- Cost and insurance status significantly impact treatment decisions, even when perceived risks and benefits are similar.
- Practice setting and patient financial factors play a critical role in the selection of expensive versus cheaper therapeutic options.
Objective:
To examine the prescribing patterns and predictors of physician choice in the selection of intravenous thrombolytic therapy for the treatment of acute myocardial infarction.
Design:
Survey of a random sample of 250 California cardiologists between July 1989 and February 1990.
Results:
The adjusted response rate was 66%. For a patient presenting within 30 minutes after the onset of an uncomplicated acute anterior-wall myocardial infarction, 98% of respondents reported that they would prescribe a thrombolytic agent, 79% chose tissue plasminogen activator, and 21% chose streptokinase. Users of tissue plasminogen activator were nine times more likely than streptokinase users to perceive tissue plasminogen activator as superior for early coronary artery recanalization, although most users of tissue plasminogen activator and streptokinase perceived no difference between the two agents for improvement in ejection fraction and mortality. Estimates of side effects did not distinguish the two groups. Users of streptokinase were eight times more likely to practice in a health maintenance organization than were users of tissue plasminogen. For a self-paying patient, 36% of users of tissue plasminogen activator said that they would switch to streptokinase, and 27% would switch for a patient insured by Medicaid.
Conclusions:
These results indicate that physicians place great emphasis on surrogate end points. Physicians vary in their willingness to use more expensive therapies over cheaper alternatives, even when their perceptions of the relative risks and benefits are similar. The patient's insurance status and the provider's practice setting may exert an important influence on doctors' clinical choices.