New post up at Practice variation in cardiology signals problems

There’s a problem in the world of cardiology. We used to be leaders in the medical world. Now, I am not so sure. We may be at an inflection point.

What would you think if cardiac procedures, like diagnostic catheterization and PCI (stents usually), varied widely depending on a patient’s geography or payment system? Your first reaction about geography variance might be that it occurred because disease varies by locale. There’s more heart disease in my state than most others, for example. That’s a good presumption except the researchers who looked at this issue controlled for age, income, sex and many other factors.

Then what if I told you that patients in two adjoining geographies, which have markedly different payment systems for procedures, had different rates of procedures, and lower yields from the procedure. Why would a payment system or geographic location affect such a well-studied medical decision as cardiac catheterization or PCI?

Two studies published in today’s issue of the Journal of the American Medical Association investigated both these issues. In one trial, researchers from Colorado found that significant variance in the rates of cardiac procedures occurred because of payment model and geography. They found patients in Medicare Advantage programs, which are capitiated and/or managed, had much lower rates of procedures than did patients in standard Medicare fee-for-service plans. The researchers looked at six million patients and also found significant variability of practice patterns based on geography.

The second study, from researchers in Toronto, compared outcomes of cardiac catheterization in New York State and Ontario Canada. Their previous work documented that NY State cardiologists did many more procedures than did their peers across the border. This study showed that the diagnostic yield (the chance of picking up positive results) was much lower in NY. In other words, cardiologists in NY cathed a much higher number of low risk patients. But this strategy (of doing more procedures) did not result in improved mortality; in fact, patients cathed in NY sustained a higher death rate.

This simply should bot be. Some degree of practice variation is to be expected, but not based on payment models and geography. I think it’s a wake up call for cardiologists. It’s time for us to look at our blemishes and accept that change needs to occur.

To read more of my thoughts click here to head over to the Trials and Fibrillations column over at


BTW: I am back, recovered from Greece, and ready to begin more regular posting.

2 replies on “New post up at Practice variation in cardiology signals problems”

I’m surprised that you’re surprised.

At least in the US, this kind of variation has been going on with other procedures as long as I can remember.

It would be interesting to see what variations there are within countries that have national health care systems, such as Canada, France, etc.

Welcome back John! I agree entirely with your last paragraph. I can think of no acceptable explanation for these findings which I do not think are new- and which I do think reflect widespread practice … It IS time for change …

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