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In the era of coronary stents, Medicare patients treated by high-volume physicians and at high-volume centers experience better outcomes following PCIs.

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Our work suggests that current efforts to address variation in cardiac procedures through activities such as appropriateness criteria, guidelines and utilization review are misdirected and should be redirected towards capacity, in this case the supply of catheterization facilities.

OBJECTIVE: Efforts to evaluate variations in cardiac procedures have focused on patient factors and differences in health care delivery systems. We wanted to assess how physicians' inclination to test patients with coronary artery disease influences utilization patterns. SETTING AND SUBJECTS:Physicians and the populations of Maine, New Hampshire, and Vermont. DESIGN:We conducted a survey of 263 family practitioners, internists, and cardiologists residing in 57 hospital service areas in Maine, New Hampshire, and Vermont. Using patient scenarios, we assessed the clinicians' inclinations to test during the evaluation of patients with coronary artery disease. Self-reported testing intensities were used to create three indices: a Catheterization Index, an Imaging Exercise Tolerance Test (ETT) Index, and a Nonimaging ETT Index. Using administrative data, age-and gender-adjusted populationbased coronary angiography rates were calculated. Physicians were assigned to low (2.9/1,000), average (4.2/1,000), and high (5.8/1,000) coronary angiography rate areas, based on where they practice. Analysis of variance techniques were used to assess the relation of the index scores to the population-based coronary angiography rates and to physician specialties. RESULTS:There was a positive relationship between the population-based coronary angiography rates and the self-reported scores of the Catheterization Index (p Ͻ .005) and the Imaging ETT Index (p ‫؍‬ .01), but none was found for the Nonimaging ETT Index (p ‫؍‬ .10). These relationships were evident in subanalyses of cardiologists and internists, but not of family practitioners. CONCLUSIONS: Self-reported testing intensity by physicians is related to the population-based rates of coronary angiography. This relationship cuts across specialties, suggesting that there is a "medical signature" for the evaluation of patients with coronary artery disease. fforts to explain the observed variation in cardiac procedures 1,2 have focused on numerous components of care. Patient factors, such as race and gender, 3-5 and health care delivery system factors, such as insurance status and characteristics of the hospital, 6-8 have been found to play a role. Less attention has been placed on how the decisions physicians make in the evaluation of patients with coronary artery disease influence utilization patterns. Recent studies, using standardized clinical scenarios, revealed differences in how physicians would treat patients with coronary artery disease. 9,10 However, there was no assessment of the relationship between the clinician's answers to these scenarios and actual practice.We surveyed family practitioners, internists, and cardiologists in Maine, New Hampshire, and Vermont to assess their inclination to test patients with chest pain and coronary artery disease. The association between their responses and the population-based utilization rates of coronary angiography was measured in order to answer two questions. Given a standardized clinical scenario, is there a relationship between cl...