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Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Supply of interventional cardiologists and the provision of lower-value Percutaneous Coronary Interventions (PCI)
Adam Gaffney1,2,3, Kelsey Chalmers3, David U Himmelstein1,4
1Harvard Medical School, Boston, Massachusetts, United States of America.
Insights
Higher numbers of heart procedure providers correlate with increased use of lower-value percutaneous coronary interventions (PCI). This suggests health planning can help align workforce supply with community needs to reduce unnecessary procedures and costs.
Area of Science:
- Cardiovascular Medicine
- Health Services Research
- Health Economics
Background:
- Percutaneous coronary interventions (PCI) are vital for acute coronary syndromes but offer less value for stable coronary artery disease (CAD).
- Previous research indicates provider supply influences healthcare utilization, but its impact on lower-value PCI is unclear.
Purpose of the Study:
- To investigate the relationship between the regional availability of PCI-performing physicians and the utilization of PCI procedures.
- To determine if a higher supply of physicians performing PCI is associated with an increased rate of lower-value PCI procedures.
Main Methods:
- Cross-sectional study utilizing 100% Medicare fee-for-service (FFS) and Medicare Advantage (MA) claims data from 2019-2021.
- Examined PCI use and lower-value PCI provision (defined as PCI for stable CAD) at hospital and regional (Hospital Referral Region - HRR) levels.
- Assessed the association between PCI provider density per million population and PCI utilization outcomes.
Main Results:
- Hospitals in regions with the highest PCI provider density had a significantly higher rate of lower-value PCI provision (22.6%) compared to those in the lowest density regions (17.3%).
- In fully adjusted models, higher provider density was linked to a 5.77 percentage point increase in lower-value PCI rates.
- Both overall PCI use and lower-value PCI use increased with greater regional PCI provider density.
Conclusions:
- The regional supply of PCI providers is associated with both the overall use of PCI and the use of lower-value PCI among Medicare beneficiaries.
- Findings support the need for health workforce planning to match provider supply with community health needs, potentially reducing healthcare costs and low-value care.
Background:
Percutaneous coronary interventions (PCI) can be lifesaving for patients with acute coronary syndromes but of lower value for patients with stable coronary artery disease (CAD). Previous studies suggest that larger provider supply drives higher healthcare utilization. Whether this is true for lower-value PCI is unknown.
Objective:
To examine the association between the regional supply of PCI-performing physicians and PCI use and lower-value use.
Design:
Cross-sectional.
Setting:
100% Medicare fee-for-service (FFS) claims and Medicare Advantage encounter data, linked to publicly available sources of population and hospital data.
Participants:
All Medicare FFS and MA beneficiaries undergoing PCI at US hospitals, 2019-2021.
Measurements:
Our exposure was the supply of PCI-performing physicians per million population in the hospital-referral-region (HRR). Our primary outcome was lower-value PCI provision defined as the share of all PCIs performed for stable CAD at the hospital-level, unadjusted and with multilevel linear regression adjustment for hospital and regional-population factors. We also examined both PCI use and lower-value use at the regional (HRR) level.
Results:
Our final dataset included 1,580 hospitals across 306 HRRs with 5,505 PCI-performing physicians. In our primary, hospital-level analysis, the lower-value PCI provision rate averaged 17.3% among hospitals located in HRRs in the lowest quintile of PCI provider density and 22.6% among hospitals in HRRs in the highest quintile. In our fully adjusted model, hospitals in the highest provider density quintile had a 5.77 percentage point higher lower-value provision rate than those in the lowest quintile (95% CI 3.70, 7.84; p < 0.01). In our HRR-level analysis, both the total number of PCIs/beneficiary and lower-value PCIs/beneficiary rose with increasing regional PCI-provider density.
Conclusions:
Among Medicare beneficiaries, the regional supply of PCI providers correlates with PCI overall and lower-value use. These findings support a role for health planning efforts to align workforce supply with community health needs to constrain both costs and the provision of low-value care.
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