Why Physicians Favor Use of Percutaneous Coronary Intervention to Medical Therapy: A Focus Group Study
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Percutaneous coronary intervention (PCI) is performed in many patients with stable coronary artery disease, despite evidence of little clinical benefit over optimal medical therapy.
To examine physicians’ beliefs, practices, and decision-making regarding elective PCI.
Six focus groups, three with primary care physicians and three with cardiologists. Participants discussed PCI using hypothetical case scenarios. Transcripts were analyzed using grounded theory, and commonly expressed themes regarding the decision-making pathway to PCI were identified.
Twenty-eight primary care physicians and 20 interventional and non-interventional cardiologists in Butte County, Orange County, and San Francisco Bay Area, California, in 2006.
A number of factors led primary care physicians to evaluate non-symptomatic or minimally symptomatic patients for coronary artery disease and refer them to a cardiologist. The use of screening tests often led to additional testing and referral, as well as fear of missing a coronary stenosis, perceived patient expectations, and medicolegal concerns. The end result was a cascade such that any positive test would generally lead to the catheterization lab, where an “oculostenotic reflex” made PCI a virtual certainty.
The widespread use of PCI in patients with stable coronary artery disease—despite evidence of little benefit in outcomes over medical therapy—may in part be due to psychological and emotional factors leading to a cascade effect wherein testing leads inevitably to PCI. Determining how to help physicians better incorporate evidence-based medicine into decision-making has important implications for patient outcomes and the optimal use of new technologies.
KEY WORDSpercutaneous coronary intervention focus groups physician decision-making qualitative study
Drs. Lin, Dudley, and Redberg had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Funding/Support: This study was funded by the Blue Shield of California Foundation. Dr. Lin is supported by a Ruth L. Kirschstein National Research Service Award (NRSA) Institutional Research Training Grant (T32).
Conference Presentations: Data from this study were presented at the Society of General Internal Medicine 30th Annual Meeting, Toronto, Ontario, April 25–28, 2007 and at the American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Conference, Washington, D.C., May 10–11, 2007.
Financial Disclosures: Dr. Redberg serves as a member of the CV Therapeutics Women’s Advisory Board. Drs. Lin and Dudley report no financial disclosures.
Role of the Sponsor: The Blue Shield of California Foundation had no role in the design and conduct of the study, in the collection, analysis, and interpretation of the data, or in the preparation, review, or approval of the manuscript.
We wish to thank the physicians who participated in our focus groups. We also wish to thank Janet Wright, MD, Morton Kern MD, Greg Thomas MD, Joshua Cohen MD, Gordon Fung, MD, Andrew Michaels MD and Ralph Brindis, MD, the UCSF Cardiology Fellows and General Internal Medicine Fellows for their feedback on case scenarios and assistance in suggesting physicians. We also acknowledge the assistance of Stephen Crane, Luciana Garcia, and Eunice Chee in setting up the focus groups.
Conflict of Interest: None disclosed.
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