The results call into question whether decision-making in for-profit hospitals is based on factors unrelated to the patient, researcher says.
Patients needing carotid revascularization are more likely to undergo stenting rather than endarterectomy if they are admitted to a for-profit rather than nonprofit hospital, according to a US-based study published online September 22, 2017, in Stroke.
Previous research looking into differences in practice among for-profit and nonprofit hospitals in the United States has produced mixed results, co-author Benjamin P. George, MD, MPH (University of Rochester, NY), told Neurovascular Exchange via email. Citing a 2015 paper in Health Affairs that found seven of the 10 most-profitable US hospitals were in fact nonprofit, George pointed out that the findings weren’t clear-cut. “This same study found that for-profit hospital status was associated with a tendency toward greater profitability when considering all US hospitals,” he noted.
To assess the implications in carotid artery disease, George along with Justin V. Chandler, MD (University of Rochester), and colleagues used Nationwide Inpatient Sample data on admissions for cerebrovascular disease that occurred between 2008 and 2011 to identify private, nonfederal US hospitals that performed at least 20 carotid revascularizations annually.
Among 723 hospitals identified, 123 were for-profit and 600 were nonprofit. A total of 66,731 admissions for carotid revascularizations—17.4% involving stenting—took place during the study period.
The mean stenting rate was higher at for-profit than at nonprofit hospitals (24.2 vs 17.5 per 100 revascularizations, P < 0.001). This remained the case even after adjusting for patient and hospital characteristics. Patients treated at for-profit versus nonprofit hospitals were 45% more likely to undergo stenting (adjusted OR 1.45; 95% CI 1.07-1.98).
Is Money a Factor?
According to George, the study findings raise concern that carotid artery stenting may be performed more commonly in for-profit hospitals for reasons of profitability.
“There are a few reasons to suspect this could be the case,” he noted. “First, reimbursement is higher on average for stenting; however, there are at least some circumstances where this may be offset by costs. Second, a Dartmouth Atlas study suggested carotid artery stenting was a supply-sensitive procedure, and therefore there is the potential to construct hospital-based programs for carotid stenting with the aim to drive profitability with procedure volume.”
George pointed out, however, that factors not accounted for in the analysis may also be at play. “Our data set was limited in elucidating the intricacies of patient illness and disease that could go into a decision to use carotid artery stenting versus endarterectomy,” he acknowledged. “We were also limited in the identification of outcomes after carotid revascularization procedures for patients within our data set.”
He recommended, therefore, that the results be interpreted with caution. Nevertheless, they do raise a red flag regarding the possibility that treatment decisions are being made in for-profit hospitals based on factors unrelated to the patient.
“The main implications are at the level of policymakers, who may be focused on creating strategies that have the potential to align incentives with optimal patient care,” said George. “This becomes especially important in situations where ongoing trials seek to answer unresolved clinical questions, such as the case with the CREST-2 trials. I think most would argue that society could benefit from more rapid trial enrollment if revascularization procedures on patients with asymptomatic carotid stenosis were limited to clinical trials. This issue with competing out-of-trial use came into play with the slow, 9-year, enrollment of the first CREST trial.”
Questions about optimal patient care remain. “An estimated 100,000 carotid revascularizations are performed per year in the US, the majority in asymptomatic individuals,” he said, but it remains unclear whether revascularization produces the best outcomes in these patients.
“Since this question remains unanswered, and many carotid artery stenting procedures are being performed on asymptomatic patients in the US, it is important to understand the potential financial and economic incentives that underlie the decision for carotid revascularization and how these may impact patient care as well as their impact on clinical trial enrollment,” George added.
Chandler JV, George BP, Kelly AG, Holloway RG. For-profit hospital status and carotid artery stent utilization in US hospitals performing carotid revascularization. Stroke. 2017;Epub ahead of print.
George reports no relevant conflicts of interest.