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Analysis of physician and hospital differences in 'negative' coronary angiogram rates
P E Dans1, J C Keruly, J A Brinker
1Office of Medical Practice Evaluation, Johns Hopkins University School of Medicine, Baltimore, MD 21205.
Insights
Physician payment models may influence coronary angiography rates. However, this study suggests hospital factors and physician judgment are also key determinants of negative angiogram results.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Medical Practice Variation
Background:
- A potential link between high rates of negative coronary angiograms and physician reimbursement structures has been proposed.
- Understanding factors influencing coronary angiography utilization and outcomes is crucial for healthcare quality and cost-effectiveness.
Purpose of the Study:
- To prospectively investigate the relationship between physician payment models (salaried vs. fee-for-service) and coronary angiogram outcomes.
- To identify other potential determinants of variation in negative coronary angiogram rates.
Main Methods:
- Prospective study comparing coronary angiography in a teaching hospital (salaried cardiologists) and a community hospital (fee-for-service cardiologists).
- Analysis of "negative" coronary angiogram rates, defined by specific criteria.
- Assessment of factors including cardiac surgery unit presence, patient referral patterns, and physician's pre-angiogram probability assessment.
Main Results:
- Lower overall negative angiogram rates were observed at the teaching hospital, correlating with the presence of a cardiac surgery unit and higher referral rates of patients with known coronary artery disease.
- No significant differences were found in the percentage of completely normal angiograms between the two hospital types.
- Rates of angiograms positive for significant coronary artery disease (≥70% occlusion) in patients without prior diagnosis did not differ substantially.
Conclusions:
- While physician reimbursement may be an incentive, it is not the sole driver of coronary angiogram variation.
- Hospital infrastructure (e.g., cardiac surgery availability) and physician's clinical judgment in assessing pre-angiogram probabilities significantly influence negative angiogram rates.
- Further research is needed to fully elucidate the multifactorial determinants of coronary angiography utilization and outcomes.
Abstract:
A direct relationship has been postulated between high "negative" coronary angiogram rates and physician payment. We conducted a prospective study of coronary angiography in a teaching and community hospital staffed, respectively, by cardiologists who were performing cardiac catheterization as salaried or fee-for-service physicians. The lower overall rate of negative angiograms at the teaching hospital correlated with the presence of a cardiac surgery unit and the increased referral of patients with documented coronary artery disease. The percentage of completely normal angiograms did not differ significantly between hospitals. The number of angiograms positive by a 70% occlusion criterion in patients not previously known to have coronary artery disease also did not differ greatly. Negative angiogram rates appeared to vary inversely with physician ability to set preangiogram probabilities of coronary artery disease. Our findings do not discount reimbursement as a strong incentive, but suggest other important determinants of coronary angiographic variation.
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