Why Physicians Favor Use of Percutaneous Coronary Intervention to Medical Therapy: A Focus Group Study

  • Grace A. Lin
  • R. Adams Dudley
  • Rita F. Redberg
Original Article

Abstract

BACKGROUND

Percutaneous coronary intervention (PCI) is performed in many patients with stable coronary artery disease, despite evidence of little clinical benefit over optimal medical therapy.

OBJECTIVE

To examine physicians’ beliefs, practices, and decision-making regarding elective PCI.

DESIGN

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.

PARTICIPANTS

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.

RESULTS

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.

CONCLUSIONS

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 WORDS

percutaneous coronary intervention focus groups physician decision-making qualitative study 

Supplementary material

11606_2008_706_MOESM1_ESM.doc (60 kb)
ESM (DOC 60.5 KB)

References

  1. 1.
    Mensah GA, Brown DW. An overview of cardiovascular disease burden in the United States. Health Aff (Millwood). 2007;26(1):38–48.CrossRefGoogle Scholar
  2. 2.
    Lepor NE. Screening CT-Coronary angiography: ready for prime time? Rev Cardiovasc Med. 2006;7:198–204.PubMedGoogle Scholar
  3. 3.
    Naghavi M, Falk E, Hecht HS, et al. From vulnerable plaque to vulnerable patient-Part III: executive summary of the Screening for Heart Attack Prevention and Education (SHAPE) Task Force report. Am J Cardiol. 2006;98(2A):2H–15H, Jul 17.PubMedCrossRefGoogle Scholar
  4. 4.
    Greenland P, Smith SC, Grundy SM. Improving coronary heart disease risk assessment in asymptomatic people: role of traditional risk factors and non-invasive cardiovascular tests. Circulation. 2001;104:1863–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Gorman C, Park A. How new heart-scanning technology could save your life. Time; 2005; Aug. 28.Google Scholar
  6. 6.
    Lee TH, Brennan TA. Direct-to-consumer marketing of high-technology screening tests. N Engl J Med. 2002;346:529–31.PubMedCrossRefGoogle Scholar
  7. 7.
    Taylor AJ, O’Malley PG. Self-referral of patients for electron-beam computed tomography to screen for coronary artery disease. N Engl J Med. 1998;339(27):2018–20.PubMedCrossRefGoogle Scholar
  8. 8.
    Wennberg DE, Birkmeyer JD, Birkmeyer NJO, et al. The Dartmouth Atlas of Cardiovascular Care. Chicago: AHA Press; 1999.Google Scholar
  9. 9.
    Wennberg DE, Kellett MA, Dickens JD, Malenka DJ, Keilson LM, Keller RB. The association between local diagnostic testing intensity and invasive cardiac procedures. JAMA. 1996;275:1161–4.PubMedCrossRefGoogle Scholar
  10. 10.
    American Heart Association. Heart Disease and Stroke Statistics - 2006 Update. Dallas, TX: American Heart Association; 2006.Google Scholar
  11. 11.
    Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503–16.PubMedCrossRefGoogle Scholar
  12. 12.
    Bucher HC, Hengstler P, Schindler C, Guyatt GH. Percutaneous transluminal coronary angioplasty versus medical treatment for non-acute coronary heart disease: a meta-analysis of randomised controlled trials. BMJ. 2000;321:73–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Katritsis DG, Ioannidis JP. Percutaneous coronary intervention versus medical therapy in nonacute coronary artery disease. Circulation. 2005;111:2906–12.PubMedCrossRefGoogle Scholar
  14. 14.
    Pitt B, Waters D, Brown WV, et al. Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease. Atorvastatin versus Revascularization Treatment Investigators. N Engl J Med. 1999;341:70–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Spertus JA, Salisbury AC, Jones PG, Conaway DG, Thompson RC. Predictors of quality-of-life benefit after percutaneous coronary intervention. Circulation. 2004;110:3789–94.PubMedCrossRefGoogle Scholar
  16. 16.
    Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics-2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115(5):e69–e171.PubMedCrossRefGoogle Scholar
  17. 17.
    Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ. 1995;311:42–5.PubMedGoogle Scholar
  18. 18.
    Krueger RA, Casey MA. Focus Groups: A Practical Guide for Applied Research. Thousand Oaks, CA: Sage Publications, Inc.; 2002.Google Scholar
  19. 19.
    Glaser B, Strauss A. The Discovery of Grounded Theory. Chicago: Aldine; 1967.Google Scholar
  20. 20.
    Strauss A, Corbin J. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage Publications; 1990.Google Scholar
  21. 21.
    Patton MQ. Enhancing the quality and credibility of qualitative analysis. Health Serv Res. 1999;34:1189–208.PubMedGoogle Scholar
  22. 22.
    Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? BMJ. 2001;322:1115–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Topol EJ, Nissen SE. Our occupation with coronary luminology: the dissociation between clinical and angiographic findings in ischemic heart disease. Circulation. 1995;92:2333–42.PubMedGoogle Scholar
  24. 24.
    Mold JW, Stein HF. The cascade effect in the clinical care of patients. N Engl J Med. 1986;314(8):512–4.PubMedGoogle Scholar
  25. 25.
    Kim CB, Braunwald E. Potential benefits of late reperfusion of infarcted myocardium. The open artery hypothesis. Circulation. 1993;88(5 Pt 1):2426–36.PubMedGoogle Scholar
  26. 26.
    Freidson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York: Harper and Row; 1970.Google Scholar
  27. 27.
    Sox HC, Margulies I, Sox CH. Psychologically mediated effects of diagnostic tests. Ann Intern Med. 1981;95:680–5.PubMedGoogle Scholar
  28. 28.
    Schwartz LM, Woloshin S, Fowler FJ, Welch HG. Enthusiasm for cancer screening in the United States. JAMA. 2004;291:71–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Holmboe ES, Fiellin DA, Cusanelli E, Remetz M, Krumholz HM. Perceptions of benefit and risk of patients undergoing first-time elective percutaneous coronary revascularization. JGIM. 2000;15(9):632–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Fisher ES, Welch HG. Avoiding the unintended consequences of growth in health care. JAMA. 1999;281:446–53.PubMedCrossRefGoogle Scholar
  31. 31.
    Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: Health outcomes and satisfaction with care. Ann Intern Med. 2003;138:273–87.PubMedGoogle Scholar
  32. 32.
    Hickson GB, Altemeier WA, Perrin JM. Physician reimbursement by salary or fee-for-service: effect on physician practice behavior in a randomized prospective study. Pediatrics. 1987;80(3):344–50, Sep.PubMedGoogle Scholar
  33. 33.
    Hillman AL, Pauly MV, Kerstein JJ. How do financial incentives affect physicians’ clinical decisions and the financial performance of health maintenance organizations? N Engl J Med. 1989;321(2):86–92, Jul 13.PubMedGoogle Scholar
  34. 34.
    Shen J, Andersen R, Brook R, Kominski G, Albert PS, Wenger N. The effects of payment method on clinical decision-making: physician responses to clinical scenarios. Med Care. 2004;42(3):297–302, Mar.PubMedCrossRefGoogle Scholar
  35. 35.
    Nallamothu BK, Rogers MAM, Chernew ME, Krumholz HM, Eagle KA, Birkmeyer JD. Opening of specialty cardiac hospitals and use of coronary revascularization in Medicare beneficiaries. JAMA. 2007;297:962–8.PubMedCrossRefGoogle Scholar
  36. 36.
    Ligthart S, Vlemmix F, Dendukuri N, Brophy JM. The cost-effectivenss of drug-eluting stents: a systematic review. CMAJ. 2007;176(2):199–205.PubMedGoogle Scholar
  37. 37.
    Dresselhaus TR, Peabody JW, Luck J, Bertenthal D. An evaluation of vignettes for predicting variation in the quality of preventive care. J Gen Intern Med. 2004;19(10):1013–8, Oct.PubMedCrossRefGoogle Scholar
  38. 38.
    Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M. Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality. JAMA. 2000;283(13):1715–22, Apr 5.PubMedCrossRefGoogle Scholar
  39. 39.
    Peabody JW, Luck J, Glassman P, et al. Measuring the quality of physician practice by using clinical vignettes: a prospective validation study. Ann Intern Med. 2004;141(10):771–80, Nov 16.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Grace A. Lin
    • 1
  • R. Adams Dudley
    • 2
  • Rita F. Redberg
    • 3
  1. 1.Division of General Internal MedicineUniversity of CaliforniaSan FranciscoUSA
  2. 2.Institute for Health Policy StudiesUniversity of CaliforniaSan FranciscoUSA
  3. 3.School of Medicine, Division of CardiologyUniversity of CaliforniaSan FranciscoUSA

Personalised recommendations