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Original Investigation
March 1, 2017

Provider-Induced Demand in the Treatment of Carotid Artery StenosisVariation in Treatment Decisions Between Private Sector Fee-for-Service vs Salary-Based Military Physicians

Author Affiliations
  • 1Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
  • 3Milken Institute School of Public Health, George Washington University, Washington, DC
  • 4Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia
JAMA Surg. Published online March 1, 2017. doi:10.1001/jamasurg.2017.0077
Key Points

Question  Is the variation in care for carotid stenosis seen between reimbursement systems consistent with the concept of provider-induced demand?

Findings  In this database study of 10 579 individuals with carotid artery stenosis, the adjusted odds of undergoing carotid endarterectomy or stenting were significantly higher in the fee-for-service setting than in the salary-based setting for both symptomatic and asymptomatic disease.

Meaning  Individuals with both symptomatic and asymptomatic carotid stenosis treated in a fee-for-service system were significantly more likely to undergo procedural management when compared with those in the salary-based system.


Importance  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.

Objective  To explore evidence for provider-induced demand in the management of carotid artery stenosis.

Design, Setting, and Participants  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.

Main Outcomes and Measures  The odds of procedural intervention based on treatment system was the primary outcome used to indicate the presence and effect of provider-induced demand.

Results  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).

Conclusions and Relevance  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.