Nguyen Louis L, Smith Ann D, Scully Rebecca E, Jiang Wei, Learn Peter A, Lipsitz Stuart R, Weissman Joel S, Helmchen Lorens A, Koehlmoos Tracey, Hoburg Andrew, Kimsey Linda G
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
JAMA Surg. 2017 Jun 1;152(6):565-572. doi: 10.1001/jamasurg.2017.0077.
Although many factors influence the management of carotid artery stenosis, it is not well understood whether a preference toward procedural management exists when procedural volume and physician compensation are linked in the fee-for-service environment.
To explore evidence for provider-induced demand in the management of carotid artery stenosis.
DESIGN, SETTING, AND PARTICIPANTS: The Department of Defense Military Health System Data Repository was queried for individuals diagnosed with carotid artery stenosis between October 1, 2006, and September 30, 2010. A hierarchical multivariable model evaluated the association of the treatment system (fee-for-service physicians in the private sector vs salary-based military physicians) with the odds of procedural intervention (carotid endarterectomy or carotid artery stenting) compared with medical management. Subanalysis was performed by symptom status at the time of presentation. The association of treatment system and of management strategy with clinical outcomes, including stroke and death, was also evaluated. Data analysis was conducted from August 15, 2015, to August 2, 2016.
The odds of procedural intervention based on treatment system was the primary outcome used to indicate the presence and effect of provider-induced demand.
Of 10 579 individuals with a diagnosis of carotid artery stenosis (4615 women and 5964 men; mean [SD] age, 65.6 [11.4] years), 1307 (12.4%) underwent at least 1 procedure. After adjusting for demographic and clinical factors, the odds of undergoing procedural management were significantly higher for patients in the fee-for-service system compared with those in the salary-based setting (odds ratio, 1.629; 95% CI, 1.285-2.063; P < .001). This finding remained true when patients were stratified by symptom status at presentation (symptomatic: odds ratio, 2.074; 95% CI, 1.302-3.303; P = .002; and asymptomatic: odds ratio, 1.534; 95% CI, 1.186-1.984; P = .001).
Individuals treated in a fee-for-service system were significantly more likely to undergo procedural management for carotid stenosis compared with those in the salary-based setting. These findings remained consistent for individuals with and without symptomatic disease.
尽管许多因素影响着颈动脉狭窄的治疗管理，但在按服务收费的环境中，当手术量与医生薪酬挂钩时，对于手术治疗管理是否存在偏好尚不清楚。
探讨在颈动脉狭窄治疗管理中供应商诱导需求的证据。
设计、设置和参与者：查询了国防部军事医疗系统数据存储库中2006年10月1日至2010年9月30日期间被诊断为颈动脉狭窄的个体。一个分层多变量模型评估了治疗系统（私营部门按服务收费的医生与基于薪水的军队医生）与手术干预（颈动脉内膜切除术或颈动脉支架置入术）相对于药物治疗的几率之间的关联。根据就诊时的症状状态进行亚组分析。还评估了治疗系统和管理策略与包括中风和死亡在内的临床结局之间的关联。数据分析于2015年8月15日至2016年8月2日进行。
基于治疗系统的手术干预几率是用于表明供应商诱导需求的存在和影响的主要结局。
在10579名被诊断为颈动脉狭窄的个体中（4615名女性和5964名男性；平均[标准差]年龄为65.6[11.4]岁），1307人（12.4%）接受了至少1次手术。在调整了人口统计学和临床因素后，与基于薪水的环境中的患者相比，按服务收费系统中的患者接受手术治疗的几率显著更高（优势比，1.629；95%置信区间，1.285 - 2.063；P <.001）。当根据就诊时的症状状态对患者进行分层时，这一发现仍然成立（有症状：优势比，2.074；95%置信区间，1.302 - 3.303；P =.002；无症状：优势比，1.534；95%置信区间，1.186 - 1.984；P =.001）。
与基于薪水的环境中的个体相比，在按服务收费系统中接受治疗的个体接受颈动脉狭窄手术治疗的可能性显著更高。对于有症状和无症状疾病的个体，这些发现均保持一致。
