Fewer stress tests, more high-risk procedures: How working at a hospital influences cardiologists
Cardiologists employed by a hospital are much more likely to perform high-intensity coronary interventions on heart patients presenting with stable angina than independent cardiologists, according to new research published in Health Affairs.[1] These findings suggest that hospital-physician integration can lead to treatment decisions associated with higher risks and higher healthcare costs.
“As a way to organize healthcare services, hospital-physician integration has generated much controversy within the health policy community,” wrote first author Brady Post, PhD, an assistant professor in the department of health sciences at Northeastern University in Boston, and colleagues. “For advocates, employed physicians are well positioned to capitalize on hospitals’ large care teams and technological resources for helping patients readily access more coordinated care, which can lead to less costly treatment and better outcomes. Opponents worry that hospitals may steer employed physicians (for example, with training, software, or compensation) toward treatment styles that are profitable for the hospital, but not necessarily cost-effective or otherwise in the best interests of patient care.”
Post et al. examined data from more than 14,500 Medicare patients who received a new diagnosis of stable angina from 2014 to 2019. All patients also had at least one appointment with a noninterventional cardiologist within 12 months of that initial diagnosis. Nearly 66% of patients were treated by an independent cardiologist, and there was “no evidence” that either group was linked to patients with more severe illness.
The researchers explained that they wanted to focus on stable angina because it is prevalent in the United States and there are multiple opportunities for the patient’s cardiologist to influence key decisions such as whether or not a stress test is ordered before treatment.
Overall, in unadjusted analyses, cardiac stress tests were ordered in 30% of cases treated by integrated cardiologists and 32% of cases treated by independent cardiologists. Stress tests are generally recommended before catheterization, the authors noted.
In addition, cardiac catheterization was seen in 38% of cases treated by integrated cardiologists and 33% of cases treated by independent cardiologists. Coronary angioplasty, meanwhile, was seen in 14% of cases treated by integrated cardiologists and 11% of cases treated by independent cardiologists.
“The results from our linear probability models were consistent with unadjusted analyses,” the authors wrote. “In these models, which adjusted for patients’ demographic and clinical characteristics, integration continued to have a significant relationship with the probability of a patient receiving services.”
While hospital integration had a “modest negative relationship with receiving a stress test” in linear probability models, it had a “positive relationship” with both catheterization and angioplasty.
In addition, the team also performed a robustness analysis that found hospital integration was linked to patients being 11.8% less likely to receive cardiac stress testing, 13.3% more likely to undergo cardiac catheterization, and 10.7% more likely to receive angioplasty.
“Our results raise the question of why integration-related changes in treatment mix may occur,” the authors wrote. “Others have noted that hospitals might incentivize or otherwise encourage their physicians to steer patients toward care that supports the hospital’s financial health, such as MRIs. Our results are consistent with this explanation, although explicit incentives might not be necessary. These changes could simply reflect employees playing to the strengths of their organization: Those in higher-tech settings can and do perform higher-tech services, especially when treating conditions that offer latitude in clinical decision making.”
The group emphasized that cardiologists make key decisions in the 12 months following a stable angina diagnosis. While embracing high-intensity services may seem like the best strategy in the moment—and it certainly is the best strategy in some instances—“excessive reliance” on these treatments can “expose patients to unnecessary risk.”
As Post and colleagues noted in their analysis, their findings did not provide conclusive answers when it comes to determining if hospital-physician integration is linked to better care or stronger, more effective health systems. However, the data do show that this trend is not making healthcare in the United States safer or less expensive—at least when it comes to this patient population.
“The primary concern from our study is that patients might be subjected to excessive risk simply because of who employs their doctor,” the authors wrote. “If one adverse outcome of hospital-physician integration is overly intense treatment, a possible additional policy response is to develop payment methods for such integrated systems that explicitly incentivize appropriate conservative treatment.”
Click here for the full study from Health Affairs.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.