Clinical Ambiguity and Conflicts of Interest in Interventional Cardiology Decision Making

Problem definition: Among the most vexing issues in the U.S. healthcare ecosystem is inappropriate use of percutaneous coronary intervention (PCI) procedures, also known as overstenting. A key driver of overstenting is physician subjectivity in eyeballing a coronary angiogram. Advanced tests such as fractional flow reserve (FFR) provide more precise and objective measures of PCI appropriateness, yet the decision to perform these tests is endogenous and not immune to clinical ambiguity associated with eyeballing. Additionally, conflicts of interest, arising from revenue-generating incentives, play a role in overstenting. Academic/practical relevance: Conventional wisdom suggests more precise diagnostic testing will help reduce overtreatment. However, the literature rarely recognizes that the testing decision is itself endogenous. Our research highlights the role of endogeneity surrounding interventional cardiology decision making. Methodology: This study uses stochastic modeling and simulation. Results: Under a low conflict-of-interest level, the physician performs the advanced test for intermediate lesions. Under a high conflict-of-interest level, however, the physician would perform the advanced test only for high-grade lesions, because of a financial disincentive: Performing the advanced test may lower PCI revenue if the test results argue against the procedure. Surprisingly, despite this disincentive, a more revenue-driven physician can be more inclined to perform the advanced test. Managerial implications: Our model leads to implications for various efforts aimed at tackling overstenting: (1) Attention should be paid not only to the sheer quantity of FFR procedures but to which patients receive FFR procedures; (2) reducing the risk of the advanced test has a behavior-inducing effect, yet a modest risk reduction may lower patient welfare; and (3) offering a bonus to the physician for performing FFR procedures equal to a third of its reimbursement rate will cause only a 5% increase in average physician payment while inducing a 26% decline in overstenting. In addition, we show implementing a bundled payment scheme may discourage the use of FFR procedures and lead to more salient overstenting.