September 18th, 2013

Disparities in Rate of Inappropriate Use of PCI

CardioExchange’s editor-in-chief Harlan Krumholz asks Paul Chan some questions about his new study in JACC that found a surprising pattern of both overuse and underuse of PCI among different populations in the U.S. For a summary of the findings, see CardioExchange’s news coverage of the paper.

Harlan KrumholzThe paper would be consistent with a hypothesis that patients for whom physicians are paid more are more likely to undergo inappropriate procedures? Is that true?

Paul Chan: Our findings by insurance status would seem to suggest this. We found a gradation by insurance status in the likelihood of undergoing an elective PCI categorized as inappropriate (i.e., with a low likelihood of clinical benefit). Whereas publicly insured patients were only 15% to 20% less likely to undergo an inappropriate PCI compared with privately insured patients, uninsured patients were half as likely. It is not clear, though, whether this was mediated at the physician level, or, more likely, at the hospitals at which predominantly uninsured and publicly insured patients received care.

Harlan KrumholzDo you think that the lower rate of procedures in non-white populations might be due to overuse in white populations?

Paul Chan: There are 2 types of potential disparities in care. I do not think that a racial difference in a “hard” clinical end point would be disputable. For instance, we have previously found that non-whites have a substantially lower rate of survival compared with whites for cardiac arrests within hospitals, and I doubt anyone would dispute that this difference is unacceptable. Where there is some uncertainty is when there is a racial difference in a treatment or an intervention. There are numerous studies which have documented underuse in a treatment in non-white populations. What our study intimates is that some of the racial differences in treatment may also be due to potential overuse. Therefore, efforts to end racial disparities may be more complex– eradicating underuse among vulnerable populations in circumstances where there is clear clinical benefit of treatment for patients, but also addressing potential overuse which may contribute to the measured racial differences.

Harlan KrumholzWhy would white men be more likely to have inappropriate procedures?

Paul Chan: We found this to be a head-scratcher, too. Unlike differences by race and insurance status, I would imagine the representation of women across Cath PCI sites was pretty homogeneous, so this difference would be unlikely to be mediated by the hospital at which men and women received care. If anything, since women are more likely to present with atypical symptoms which could be coded as having no or minimal symptoms, I would not have been surprised were women found to have higher rates of PCIs categorized as inappropriate. It could be that women’s propensity to have more common presentations of diffuse coronary artery disease may have led to less aggressive treatment in clinical settings where symptoms, angiographic findings, and stress test results were not high-risk (i.e., less frequent PCIs for inappropriate indications).

Harlan KrumholzWhat are the implications of these findings for clinicians and policymakers?

Paul Chan: We have come a long way in ensuring that care is delivered equitably and thoughtfully in the U.S., and there is no doubt that underuse in certain populations remains a persistent and huge problem. For policymakers, as mentioned in my response to the second question, it highlights the importance of thinking about differences in treatment in a more complex way– as due to underuse and also potential overuse. Therefore, the goal may be to narrow the gap in vulnerable populations in instances where treatment has clearly established benefit rather than assuming that the measured difference is entirely due to a disparity in care.

4 Responses to “Disparities in Rate of Inappropriate Use of PCI”

  1. Enrique Guadiana, Cardiology says:

    I don’t think that patients for whom physicians are paid more are more likely to undergo inappropriate procedures. Many times is all the contrary. You have to include in the study the subjective differences in patients, the real cost for them, not the amount.

    Privately insured patients pay a lot of money for many years for their policies so when they get sick many think it is time to collect so they want the best care and for them the best is lineal to expensive, they are very demanding, then add the overwhelming therapeutic misconception the general public has about PCI, 80 to 90% of the patients are convinced that after PCI they will have less MI and lower risk of death even after you explain them the facts of OMT vs PCI, so many of them demand PCI and many doctors accommodate them.

    Patients with public insurer pay less money for their benefice, they are not in the same position to demand, they ask more questions because many of them don’t completely trust the public health system and at the end they always pay more pocket money, and they really need that money, so they are more alert.

    Patients with no insurance are more inquisitive, they want to know the cost in advance and the benefit of any procedure because they want to know if they can aford it and if they really need it. Many of them pay very well to their doctors and if they can’t, many doctors help them, and many patients at the end are very great full so they develop healthy doctor-patients relations.

    I don’t like these kind of studies, some times I feel they have an occult agenda.

  2. Wayne Powell, BA, MPS says:

    Just a basic question here. Has anyone ever compared the NCDR data fields on AUC with actual medical records? Could it be that in the early days of AUC (when this data was collected) that many of the NCDR records were incomplete? Now that physicians are getting feedback on their AUC scores, I suspect accuracy (or at least completeness) is increasing.

  3. Joel Wolkowicz, MDCM says:

    I beg to differ with Dr. Guadiana. These studies reveal that important decisions about medical care are being made for the wrong reasons. If doctors don’t think it is important to look into it, politicians and insurance companies will do it for us.

    • Enrique Guadiana, Cardiology says:

      I beg to differ with Dr Wolkowikcz. I have read a lot of comment from him and I don’t understand this one. The important decisions for many many years about medical care are being maid by politicians and insurance companies, not us. At least in the real word.

      We are physicians, do you want to discus the theoretical word or the real word. Do you believe in heaven and in hell, well the world is between them. We study many years and overcome meany obstacles to become doctors. Then a bunch of unscrupulous people decide medicine is a good business so they enter the “business”‘, then they want to decide the correct “revenue” for our work. I wonder they do this because is correct or so they increase they profit, Ok what about the other professions, why not them? No only us.

      Many of us give discount, if you give it to a patient he is great full, but if you give lt to a insurance company they will not pass it to their clients, so they will continue to assume you charge a lot.

      The insurance company decide many year ago that intellectual work is cheap, but if you insert a catheter or you operate or do something with your hands, then is different. Why we have so many procedures? I wander why?

      The most difficult part of our profession is the diagnosis, after that Google is easy. I have a teacher who told me the easy part in surgery is to operate, the difficult part is to know when to operate.

      Our profession is under attack, they say we are mercantilist, fine I really don’t know, but I am sure not more that any other professions, and maybe less. I will be happy to read a study about lawyers, architects, politicians, etc. no we are the evil.

      The system rewards the corrupt. The problem is not us, is the system. If you are a gynecologist and you decide to conduct a labor in the middle of the night because is the right thing to do, you risk in exchange to be pay less, you family will see you less, if something get wrong a lawsuit is in order, etc. So “We are not made of wood we are flesh”.

      I think very much like you, both not many people. The people who succumbs to the system are much better, they even have prestige, so is time to speak the true. The insurance companies rewards the unscrupulous, is wrong, but until they stop it will continue. They say, unscrupulous conduct affect their revenue but the effect is all the contrary, since we are the evil and charge to much, they will protect the world, all the families from us, with a fantastic policies, until they use them and become aware is not true.