Practice‐Level Variation in Outpatient Cardiac Care and Association With Outcomes

Abstract

BackgroundUtilization of cardiac services varies across regions and hospitals, yet little is known regarding variation in the intensity of outpatient cardiac care across cardiology physician practices or the association with clinical endpoints, an area of potential importance to promote efficient care.Methods and ResultsWe included 7 160 732 Medicare beneficiaries who received services from 5635 cardiology practices in 2012. Beneficiaries were assigned to practices providing the plurality of office visits, and practices were ranked and assigned to quartiles using the ratio of observed to predicted annual payments per beneficiary for common cardiac services (outpatient intensity index). The median (interquartile range) outpatient intensity index was 1.00 (0.81–1.24). Mean payments for beneficiaries attributed to practices in the highest (Q4) and lowest (Q1) quartile of outpatient intensity were: all cardiac payments (Q4 $1272 vs Q1 $581; ratio, 2.2); cardiac catheterization (Q4 $215 vs Q1 $64; ratio, 3.4); myocardial perfusion imaging (Q4 $253 vs Q1 $83; ratio, 3.0); and electrophysiology device procedures (Q4 $353 vs Q1 $142; ratio, 2.5). The adjusted odds ratios (95% CI) for 1 incremental quartile of outpatient intensity for each outcome was: cardiac surgical/procedural hospitalization (1.09 [1.09, 1.10]); cardiac medical hospitalization (1.00 [0.99, 1.00]); noncardiac hospitalization (0.99 [0.99, 0.99]); and death at 1 year (1.00 [0.99, 1.00]).ConclusionSubstantial variation in the intensity of outpatient care exists at the cardiology practice level, and higher intensity is not associated with reduced mortality or hospitalizations. Outpatient cardiac care is a potentially important target for efforts to improve efficiency in the Medicare population.

Association Between Inpatient Echocardiography Use and Outcomes in Adult Patients With Acute Myocardial Infarction

“…In contrast to these studies, our findings are consistent with several studies showing that higher rates of echocardiography testing are not associated with improved patient outcomes. Clough et al demonstrated that higher rates of outpatient echocardiography, catheterization, and myocardial perfusion imaging were not associated with differences in mortality or hospitalization in an outpatient Medicare cohort, which was similar to the findings of Kini and colleagues in a population with heart failure. Similarly, Safavi et al found that higher noninvasive imaging for suspected acute coronary syndrome was associated with higher rates of hospitalization and invasive procedures but no changes in patient-centered outcomes.…”

“…However, we believe this situation is less likely because we saw little association between an inpatient echocardiogram and 3-month readmission. Moreover, prior studies have shown no association between echocardiography testing intensity and long-term outcomes, including readmission . Third, although our data set captures echocardiography and cardiac imaging testing, the results of these tests (such as LVEF) are unknown.…”

Practice variation and practice guidelines: Attitudes of generalist and specialist physicians, nurse practitioners, and physician assistants

“…[ 2 , 3 ] Unwarranted variation has been linked to suboptimal outcomes[ 4 – 8 ] and to increased cost for the same outcome (i.e., inefficient care). [ 9 , 10 ]…”

Associations Among Practice Variation, Clinician Characteristics, and Care Algorithm Usage: A Multispecialty Vignette Study

“…2 Lower variation has been associated with better outcomes 3-5 and with decreased cost for the same outcome (ie, greater value). 6-8 The present study quantitatively evaluated characteristics of individual clinicians associated with unwarranted practice variation, and how clinical care algorithms influence this variation.…”