title: Provider-Induced Demand in the Treatment of Carotid Artery Stenosis: Variation in Treatment Decisions Between Private Sector Fee-for-Service vs Salary-Based Military Physicians.
abstract: 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.
  
  
  
  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.
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Louis L
authors.initials: LL
authors.lastname: Nguyen
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Ann D
authors.initials: AD
authors.lastname: Smith
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Rebecca E
authors.initials: RE
authors.lastname: Scully
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Wei
authors.initials: W
authors.lastname: Jiang
authors.affiliation: Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Learn
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Stuart R
authors.initials: SR
authors.lastname: Lipsitz
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Joel S
authors.initials: JS
authors.lastname: Weissman
authors.affiliation: Milken Institute School of Public Health, George Washington University, Washington, DC.
authors.forename: Lorens A
authors.initials: LA
authors.lastname: Helmchen
authors.affiliation: Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
authors.forename: Tracey
authors.initials: T
authors.lastname: Koehlmoos
authors.affiliation: Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
authors.forename: Andrew
authors.initials: A
authors.lastname: Hoburg
authors.affiliation: Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia.
authors.forename: Linda G
authors.initials: LG
authors.lastname: Kimsey
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000191:economics* / Q000601:surgery*; D003661:Decision Support Techniques; D016894:Endarterectomy, Carotid / Q000191:economics*; D018588:Fee-for-Service Plans / Q000191:economics*; D005260:Female; D017048:Health Care Costs; D006301:Health Services Needs and Demand / Q000191:economics*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008887:Military Medicine / Q000191:economics*; D015999:Multivariate Analysis; D016017:Odds Ratio; D010819:Physician's Role; D012051:Reimbursement Mechanisms / Q000191:economics*; D012456:Salaries and Fringe Benefits; D015607:Stents / Q000191:economics*; D014481:United States; D019564:Unnecessary Procedures / Q000191:economics