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Heart procedure variations go beyond incentives

By Andrew M. Seaman

NEW YORK (Reuters Health) - How doctors are reimbursed may not completely explain the difference in the number of common heart procedures performed across different geographic regions, according to a new study.

Researchers found the rate of non-emergency procedures doctors performed varied widely across 12 states regardless of how they were paid - with a lump sum or per procedure.

"It should be pretty disconcerting that you're four times more likely to get a procedure just because you walk into a hospital in one part of the country than another," said Dr. Daniel Matlock, the study's lead author from the University of Colorado Denver School of Medicine.

He and his colleagues analyzed how often common heart procedures - such as ones done to check for blocked blood vessels or to open vessels with a balloon - were performed in 12 states between 2003 and 2007. They looked at both the Medicare fee-for-service program and the Medicare Advantage program, which pays a fixed amount of money per patient.

Most previous research on variations in care has focused on fee-for-service programs, which pay doctors for each test and treatment.

Geographic variations within both programs, however, would suggest differences are about more than some doctors having financial incentives to do more, the researchers write in The Journal of the American Medical Association.

They found that Medicare Advantage patients were less likely to undergo the heart procedures, but there were still wide variations between geographic areas under both payment systems.

For example, each year, depending on the state, between 10 and 41 people for every 1,000 on a Medicare Advantage plan had a procedure to check for blocked blood vessels to the heart, compared to 16 to 44 per 1,000 Medicare fee-for-service patients.

Those variations, according to Matlock, persisted when he and his colleagues accounted for patients' age, sex, race and risk factors for heart disease.

The new study can't say why some areas of the country do more procedures than others, however.

DIFFERENCES BETWEEN COUNTRIES

In another study published in the same journal, researchers from Canada and the U.S. also found differences in the type of patients who are selected to undergo heart procedures in the two countries.

Previous research found that doctors in New York State perform about twice as many procedures to check for and open blocked blood vessels, compared to doctors in the Canadian province of Ontario.

"One possible explanation is that there is a greater burden of coronary artery disease in New York… The other possibly is that there are differences in the manner in which doctors choose patients (between New York and Ontario)," said Dr. Harindra Wijeysundera, one of the study's authors from the Institute for Clinical Evaluative Sciences in Toronto.

The new study found patients in Ontario who were selected for the procedure had a higher predicted chance of having a blockage, given their other health conditions. And based on the procedures, more of them were diagnosed with artery disease - 45 percent, versus about 30 percent of New Yorkers.

Dr. Harlan Krumholz of Yale University in New Haven, Connecticut, who wrote an editorial accompanying the two studies, said they are evidence of a decision process that's not patient-centered.

"I think I hear people say a lot that they want to eliminate variation. You don't want to eliminate variation, but you want the variation to originate from (patients)," Krumholz told Reuters Health.

"We've got to get back to thinking about how to put the patient in the middle and I think that would be a better healthcare system," he said.

Matlock agreed that patient perspectives are important.

"Doctors oversell the benefits and undersell the risks… Bringing the patient's perspective into that decision is really helpful," he said.

SOURCE: http://bit.ly/JOTmp1 The Journal of the American Medical Association, online July 9, 2013.

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