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Wasfy JH, Hidrue MK, Yeh RW, Armstrong K, Dec GW, Pomerantsev EV, Fifer MA, Ferris TG. Differences Among Cardiologists in Rates of Positive Coronary Angiograms. J Am Heart Assoc 2015; 4:e002393. [PMID: 26475298 PMCID: PMC4845144 DOI: 10.1161/jaha.115.002393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Understanding the sources of variation for high‐cost services has the potential to improve both patient outcomes and value in health care delivery. Nationally, the overall diagnostic yield of coronary angiography is relatively low, suggesting overutilization. Understanding how individual cardiologists request catheterization may suggest opportunities for improving quality and value. We aimed to assess and explain variation in positive angiograms among referring cardiologists. Methods and Results We identified all cases of diagnostic coronary angiography at Massachusetts General Hospital from January 1, 2012, to June 30, 2013. We excluded angiograms for acute coronary syndrome. For each angiogram, we identified clinical features of the patients and characteristics of the requesting cardiologists. We also identified angiogram positivity, defined as at least 1 epicardial coronary stenosis ≥50% luminal narrowing. We then constructed a series of mixed‐effects logistic regression models to analyze predictors of positive coronary angiograms. We assessed variation by physician in the models with median odds ratios. Over this time period, 5015 angiograms were identified. We excluded angiograms ordered by cardiologists requesting <10 angiograms. Among the remaining 2925 angiograms, 1450 (49.6%) were positive. Significant predictors of positive angiograms included age, male patients, and peripheral arterial disease. After adjustment for clinical variables only, the median odds ratio was 1.23 (95% CI 1.0–1.36), consistent with only borderline clinical variation after adjustment. In the full clinical and nonclinical model, the median odds ratio was 1.07 (95% CI 1.07–1.20), also consistent with clinically insignificant variation. Conclusions Substantial variation exists among requesting cardiologists with respect to positive and negative coronary angiograms. After adjustment for clinical variables, there was only borderline clinically significant variation. These results emphasize the importance of risk adjustment in reporting related to quality and value.
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Affiliation(s)
- Jason H Wasfy
- Massachusetts General Physicians Organization, Harvard Medical School, Boston, MA (J.H.W., M.K.H., T.G.F.) Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (J.H.W., R.W.Y., W.D., E.V.P., M.A.F.)
| | - Michael K Hidrue
- Massachusetts General Physicians Organization, Harvard Medical School, Boston, MA (J.H.W., M.K.H., T.G.F.)
| | - Robert W Yeh
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (J.H.W., R.W.Y., W.D., E.V.P., M.A.F.)
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (K.A., T.G.F.)
| | - G William Dec
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (J.H.W., R.W.Y., W.D., E.V.P., M.A.F.)
| | - Eugene V Pomerantsev
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (J.H.W., R.W.Y., W.D., E.V.P., M.A.F.)
| | - Michael A Fifer
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (J.H.W., R.W.Y., W.D., E.V.P., M.A.F.)
| | - Timothy G Ferris
- Massachusetts General Physicians Organization, Harvard Medical School, Boston, MA (J.H.W., M.K.H., T.G.F.) Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (K.A., T.G.F.) Partners Healthcare, Boston, MA (T.G.F.)
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