Participating hospitals "are getting a line-item list of every patient labeled inappropriate, and they're encouraged to compare that with the national average, and with their prior quarter for that hospital, and then go back to the patient records...to understand why that patient underwent the procedure to begin with," he says.
Strong suspicions exist among cardiologists I've spoken with that regional comparisons will reveal dramatic variation.
Elliott Fisher, MD, co-principal investigator of the Dartmouth Atlas, known for highlighting regional variation in expensive hospital procedures, believes the problem of inappropriate cardiovascular procedures would almost disappear if hospitals set up decision tools for patients before they have their procedures.
Fisher says the burden is on hospitals that perform angioplasty to show "that they are using validated decision aids and methods for shared decision making. In the absence of those, some patients are receiving surgery who would not have chosen it. And that is wrong patient surgery, a problem as serious as wrong-side surgery," he says.
Too many physicians have 'oculostenotic reflex'
Unfortunately, Fisher says, "too many physicians have 'oculostenotic reflex.' They see a blockage and say, 'Gosh, I can fix that. Because fixing the blockage must be good for the patient. It can't hurt them.' "
Even though it might.
Chan agrees that tools for informed decision making are rarely offered to patients prior to cardiovascular procedures.
"Often times, in the case of angioplasty, the discussion is very short before the procedure, and it's really just a list, often in legalese of what the complication rates and risks may be," Chan says. "[Cardiologists] don't even elicit patient preference as to how patients would want to manage their angina if they were found to have significant blockages during the catheterization."
Chan realizes that realignment of payment models will remove financial incentives to perform unnecessary procedures, but that is years away for most healthcare systems.
"We live in a quick-fix society," Chan says. "I'm also a trained pediatrician, and I often see families who want an antibiotic for their child's cold, even knowing it wasn't likely to benefit, because they think having something in hand is better than just waiting for the cold to get better.