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One of the ways to examine the efficiency and efficacy of different approaches to medical care is to study variations in the types of care delivered in different areas and then compare the outcomes.  The Dartmouth Atlas Working Group at Dartmouth Medical School uses Medicare data to conduct this type of small area analysis

In 2006, the group reported that residents of Elyria, Ohio, received angioplasties at four times the national average.  Angioplasty is an invasive, nonsurgical procedure widely utilized for treating heart attacks and alleviating symptoms of heart disease.  It is also used in cases of severe heart disease in hope of possibly preventing future heart attacks.  The procedure involves pushing a collapsed balloon into the coronary artery and then expanding the balloon to press plaque against the arterial wall.  Often a stent is left behind in an effort to keep the artery open.  Other approaches to heart disease include drug therapy, lifestyle changes, and coronary artery bypass grafts.  The latter procedure requires open heart surgery.

Elyria has a population of 54, 533 (2010 census) and is the county seat of Lorain County.  In 2003, the rate of angioplasties in Elyria was 42 procedures per 1,000 Medicare enrollees.  By comparison, the rate for all of Ohio that year was 13.5, and the national rate was 11.3..  All but 2 of the 35 cardiologists in Elyria at the time belonged to the North Ohio Heart Center, which relied heavily on angioplasties.  The center performed 3,400 angioplasties in 2004 (Abelson, 2006c).

There is considerable controversy about different treatment options for blocked coronary arteries.  Some experts, according to an August 2006 New York Times article on the Dartmouth findings, "say that they are concerned that Elyria is an example, albeit an extreme one, of how medical decisions in this country can be influenced by financial incentives and professional training more than solid evidence of what works best for a particular person" (Abelson, 2006c).

According to medical historian Dr. David S. Jones, neither angioplasties nor coronary bypass surgery have been shown to prolong life except in cases of severe disease.  Risks associated with bypass surgery include infections and brain damage resulting in memory loss cognitive impairment.  One of the concerns with angioplasty is that most heart attacks stem from tiny, often invisible lesions, and angioplasties tend to target the larger lesions that show up on angiograms.  he argues for a greater focus on prevention through medicines and life-style changes (Park, 2013).  

Angioplasty and coronary bypass surgery are highly profitable, and together they make up a $100 billion a year industry in the United States.  At the time of the Dartmouth study, Medicare was paying Elyria's community hospital $11,000 for angioplasty with a coated stent, and the cardiologist performing the procedure received about $800.  Bypasses however, were performed by surgeons from the Cleveland Clinic who had privileges at the community hospital.  Those surgeons received up to $2,200 per operation, and the hospital would receive up to $25,000.

OUTCOMES:

The founder and president of the North Ohio Heart Center responded to the Dartmouth findings by telling the New York Times that the center had good results with its patients and attributed the high use of angioplasty to early diagnostic interventions and aggressive treatment of coronary heart disease and to concerns about patient safety.  Because of safety concerns, the center treats many of its patients in stages, doing more than one admission and procedure.  Other cardiologists might perform multiple procedures at the same time.  Thirty-one percent of the Elyria center's patients underwent multiple admissions and procedures, about three times the rate in Cleveland.  Insurers report that the hospital's results are good, and United Health has named it a center of excellence for heart care.  

DISCUSSION QUESTIONS:

1. What do you think about using small area studies based on large Medicare databases, such as the one presented here, to identify outliers?

2.  Salaried cardiologists at Kaiser Permanente in northern Ohip used drugs more often and performed cardiac procedures at slightly below the national rate.  What role might different financial incentives be playing here?

3.  If you were Anthem Blue Cross and Blue Shield in Ohio, what studies would you conduct to attempt to explain and/or deal with these striking local differences in treatments and cost?