Key result
Physician self-referral for angiography was associated with a lower likelihood of detecting obstructive CAD compared with nonself-referral (49.8% vs 53.5%; OR 0.89; 95% CI 0.86-0.93; P<0.001).
Why the study?
Do system and physician factors impact the detection rate of obstructive coronary artery disease during diagnostic angiography for stable ischemic heart disease?
Cohort (n=60,986)
Yes
Do system and physician factors impact the detection rate of obstructive coronary artery disease during diagnostic angiography for stable ischemic heart disease?
System and physician factors, such as self-referral and hospital capabilities, significantly influence the diagnostic yield of elective coronary angiography for stable ischemic heart disease.
May warrant caution on self-referral for elective angiography; hypothesis-generating for incentives and appropriateness criteria.
BACKGROUND: Wide variation exists in the detection rate of obstructive coronary artery disease (CAD) with elective coronary angiography for suspected stable ischemic heart disease. We sought to understand the incremental impact of nonclinical factors on this variation. METHODS AND RESULTS: We included all patients who underwent coronary angiography for possible suspected stable ischemic heart disease, from October 1, 2008, to September 30, 2011, in Ontario, Canada. Nonclinical factors of interest included physician self-referral for angiography, the physician type (invasive or interventional), and hospital type. Hospitals were categorized into diagnostic angiogram only centers, stand-alone percutaneous coronary intervention centers, or full service centers with coronary artery bypass surgery available. Multivariable hierarchical logistic models were developed to identify system and physician-level predictors of obstructive CAD, after adjustment for patient factors. Our cohort consisted of 60 986 patients, of whom 31 726 had obstructive CAD (52.0%), with significant range across hospitals from 37.3% to 69.2%. Fewer self-referral patients (49.8%) had obstructive CAD compared with nonself-referral patients (53.5%), with an odds ratio of 0.89 (95% confidence interval, 0.86-0.93; P<0.001). Angiograms performed by invasive physicians had a lower likelihood of obstructive CAD compared with those by interventional physicians (48.2% versus 56.9%; odds ratio, 0.85; 95% confidence interval, 0.81-0.90; P<0.001). Fewer angiograms at diagnostic only centers showed obstructive CAD (42.0%) compared with full service centers (55.1%; odds ratio, 0.62; 95% confidence interval, 0.39-0.98; P=0.04). Nonclinical factors accounted for 23.8% of the variation between hospitals. CONCLUSIONS: Physician and system factors are important predictors of obstructive CAD with coronary angiography.
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Wijeysundera et al. (2014) conducted a cohort in suspected stable ischemic heart disease (n=60,986). Physician self-referral for angiography vs. Nonself-referral was evaluated on Detection of obstructive coronary artery disease (CAD) (OR 0.89, 95% CI 0.86-0.93, p=<0.001). Physician self-referral for angiography was associated with a lower likelihood of detecting obstructive CAD compared with nonself-referral (49.8% vs 53.5%; OR 0.89; 95% CI 0.86-0.93; P<0.001).
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