Quote:
Originally Posted by blueash
A very troubling article in the Journal of the American Medical Association [JAMA] which analyzed the likelihood that a patient with carotid stenosis, narrowing of the artery in the neck leading to the brain, would have a surgical intervention.
Records of patients in the TRICARE military health insurance system were reviewed. Within that insurance there are both fee for service [FFS] doctors and salaried doctors. Obviously one of these kinds of doctors makes more money if there is an operation, the other does not. Only patients seen by a specialist with a confirmed diagnosis were included.
The result summary:
The authors attempted to control for some variation in the patients who were enrolled in the FFS vs Salaried systems. After adjusting for these differences the FFS patients had 150% to 200% more surgeries than the salaried patients.
But you ask, didn't those who received surgery do better? Maybe those salaried doctors were not sending patients who needed operations to the OR? The authors also looked at outcome data.
Outcomes were evaluated at 30 days, one year, and two years:
Caveats.. Who needs surgery is not settled and doctors can see the same patient and make differing recommendations even if they do not have a financial stake in the outcome. Additionally it could have been that patients seen by FFS doctors were sicker and therefore needed more surgery. But the majority of patients had no symptoms and even with no symptoms the FFS patients had 150% of the surgeries of the salaried patients.
My conclusion is you should get more than one opinion before having carotid stenosis surgery. This is not to suggest that the surgeon is consciously thinking about dollars when recommending surgery. It can all be a subconscious influence of being aware of the need to generate billings to keep the practice afloat, or pay for the next trip to Tahiti. |
Everyone, please be very, VERY careful in interpreting the results of this single study. I have not read this particular article, but there are many questions that arise
First, surgical vs. medical management of carotid stenosis is somewhat controversial to start with. Vascular surgeons believe in surgery, it is what they are trained to do, and it has very little to do with "Tahiti".
Second, most carotid stenosis are discovered by the patient's internist, either because he heard a bruit, the patient had symptoms, or they went for a screening ultrasound. The patient would be started on an anti-platelet agent and referred to a vascular surgeon. So who is "fee for service" and who is "on salary" The internist? The surgeon? Both? Neither? As you can imagine, this has a tremendous effect on this study
Third, is there a bias among the researchers? The very fact that the point of the study was to look at surgical rates in fee for service vs. salaried models suggests they were trying to prove an economic, not a medical point.
Fourth, what was the study size? If small, a single cowboy of a surgeon who is bringing 40-50% stenosis to the OR can skew the whole study.
Fifth, this is a study within a single insurance plan, which makes it problematic at best and subject to certain rules that might impact the study. Who gets a carotid duplex within this insurance plan. Just symptomatic patients? Any bruit? Or do they do routine screening. These rules will skew the patient base for the whole study.
About 20-25 years ago there was a "study" that showed(with p values < .001) that patients taking calcium channel blockers for hypertension were at far greater risk for stroke, heart attack and CHF. It must have been a slow news day because the study was picked up by the AP wire and then the excrement hit the fan. For the next 2 weeks the academic cardiologists were on the talk show and news circuit doing damage control, since thousands of people stopped taking their medication. Turns out the study was done entirely within the Harvard Medical Plan, a Boston based HMO. The problem was that this HMO had a "rule", that only patients with "complicated" HTN could be treated with a Ca++ channel blocker, otherwise they would get a diuretic and B-blocker. Therefore, the entire study was skewed to select the most severe cases of HTN to start with, so naturally all the complication rates were higher
Sixth, as far as outcome goes, what was the breakdown of percentage of stenosis? Generally, patients with high grade stenosis will do better with surgery and low grade stenosis can be treated medically. If I was trying to prove a point in a study, I'd lump them all together, especially if there were patients getting surgery for low grade stenosis.
Seventh, this was a retrospective study based on chart review---not the best type of study to start with.
Bottom line, if you happen to be discovered to have carotid stenosis, see a quality vascular surgeon; I doubt he will have "Tahiti" on his mind. For me personally, he would have to kidnap me to operate on a 50% stenosis, but with 90% I want my surgery yesterday.