title: Practice-Level Variation in Outpatient Cardiac Care and Association With Outcomes.
abstract: BACKGROUND
  Utilization of cardiac services varies across regions and hospitals, yet little is known regarding variation in the intensity of outpatient cardiac care across cardiology physician practices or the association with clinical endpoints, an area of potential importance to promote efficient care.
  
  
  RESULTS
  We included 7 160 732 Medicare beneficiaries who received services from 5635 cardiology practices in 2012. Beneficiaries were assigned to practices providing the plurality of office visits, and practices were ranked and assigned to quartiles using the ratio of observed to predicted annual payments per beneficiary for common cardiac services (outpatient intensity index). The median (interquartile range) outpatient intensity index was 1.00 (0.81-1.24). Mean payments for beneficiaries attributed to practices in the highest (Q4) and lowest (Q1) quartile of outpatient intensity were: all cardiac payments (Q4 $1272 vs Q1 $581; ratio, 2.2); cardiac catheterization (Q4 $215 vs Q1 $64; ratio, 3.4); myocardial perfusion imaging (Q4 $253 vs Q1 $83; ratio, 3.0); and electrophysiology device procedures (Q4 $353 vs Q1 $142; ratio, 2.5). The adjusted odds ratios (95% CI) for 1 incremental quartile of outpatient intensity for each outcome was: cardiac surgical/procedural hospitalization (1.09 [1.09, 1.10]); cardiac medical hospitalization (1.00 [0.99, 1.00]); noncardiac hospitalization (0.99 [0.99, 0.99]); and death at 1 year (1.00 [0.99, 1.00]).
  
  
  CONCLUSIONS
  Substantial variation in the intensity of outpatient care exists at the cardiology practice level, and higher intensity is not associated with reduced mortality or hospitalizations. Outpatient cardiac care is a potentially important target for efforts to improve efficiency in the Medicare population.
authors.affiliation: Centers for Medicare and Medicaid Services, Baltimore, MD Duke Clinical Research Institute, Department of Medicine, Duke University, Durham, NC Jeffrey.clough@duke.edu.
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Clough
authors.affiliation: Centers for Medicare and Medicaid Services, Baltimore, MD.
authors.forename: Rahul
authors.initials: R
authors.lastname: Rajkumar
authors.affiliation: Department of Medicine, Emory University, Atlanta, GA.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Crim
authors.affiliation: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT.
authors.forename: Lesli S
authors.initials: LS
authors.lastname: Ott
authors.affiliation: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT.
authors.forename: Nihar R
authors.initials: NR
authors.lastname: Desai
authors.affiliation: Centers for Medicare and Medicaid Services, Baltimore, MD.
authors.forename: Patrick H
authors.initials: PH
authors.lastname: Conway
authors.affiliation: Centers for Medicare and Medicaid Services, Baltimore, MD.
authors.forename: Sha
authors.initials: S
authors.lastname: Maresh
authors.affiliation: Centers for Medicare and Medicaid Services, Baltimore, MD.
authors.forename: Daver C
authors.initials: DC
authors.lastname: Kahvecioglu
authors.affiliation: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT Department of Health Policy and Management, Yale School of Public Health, New Haven, CT.
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000191:economics / Q000639:trends*; D002309:Cardiology / Q000191:economics / Q000639:trends*; D005260:Female; D017048:Health Care Costs / Q000639:trends; D054625:Healthcare Disparities / Q000191:economics / Q000639:trends*; D006331:Heart Diseases / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000628:therapy*; D006760:Hospitalization / Q000639:trends; D006801:Humans; D008297:Male; D006278:Medicare; D008875:Middle Aged; D009819:Office Visits / Q000639:trends; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000639:trends*; D017064:Process Assessment, Health Care / Q000191:economics / Q000639:trends*; D019984:Quality Indicators, Health Care / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
keywords: mortality; physician practice variation; population