Institutional Differences in Therapeutic Decision Making in the Coronary Artery Surgery Study (CASS)

Abstract

This article examines institutional differences in therapeutic decision making in the Coronary Artery Surgery Study (CASS). The initial decision to use medical therapy or coronary artery bypass surgery for coronary artery disease is studied. Data from the CASS registry and a survey of CASS principal investigators were used to examine the effects of institutional characteristics, individual physician characteristics, and decision making responsibility on the recommended therapy, the actual therapy, and the ratio of the observed to expected number of surgeries. The results indicated that the experience and involvement of the surgeon in the decision making process were related to actual and recommended rates of surgery. The percentage of urgent transfers from other hospitals and the percentage of surgical referrals to outside hospitals were related to the ratio of the observed to expected numbers of surgery, an adjusted rate of surgery. A major conclusion of this study is that despite the effects of certain institutional constructs, scientific criteria in the form of clinical and angio graphic data are the most important determinants of whether a patient receives coronary artery bypass surgery.

Keywords

Key words: therapeutic decision making Coronary Artery Surgery Study institutional factors. (Med Decis Making 6:127-135 1986)

Get full access to this article

View all access options for this article.

References

Alderman EL , Fisher LD , Maynard C. , et al: Determinants of coronary surgery in a consecutive patient series from geographically dispersed medical centers. Circulation 66 (suppl I):I-6-I-15, 1982

Campeau L. : Grading of angina pectoris. Circulation 54:522-523, 1976

Directory of Medical Specialists, 20th ed. Chicago, Marquis Who's Who, 1981

Eisenberg JM : Sociologic influences on decision making by clinicians. Ann Intern Med 90:957-964, 1979

Elstein AS , Rovner DL , Holzman GB , et al: Psychological approaches to medical decision making. Am Behav Sci 25:557-584, 1982

Flood AB , Scott WR : Professional power and professional effectiveness: the power of the surgical staff and the quality of surgical care in hospitals. J Health Soc Behav 19:240-254, 1978

Halperin M. , Blackwelder WL , Verter JI : Estimation of the multivariate logistic risk function: a comparison of the discriminant function and maximum likelihood approaches. J Chronic Dis 24:125-158, 1971

Katz P. : How surgeons make decisions, in Hahn RA , Gaines AD (eds): Physicians of Western Medicine . Dordrecht, D. Reidel Publishing Company, 1985, pp 155-175

Kleinbaum DG , Kupper LL , Morgenstern H. : Epidemiologic Research. Belmont, CA, Lifetime Learning Publications, 1982, pp 420-428

10.

Luft HS , Bunker JP , Enthoven AC : Should operations be regionalized ? An empirical study of the relation between surgical volume and mortality. N Engl J Med 301:1364-1369, 1979

11.

Miller DW : The Practice of Coronary Artery Bypass Surgery. New York , Plenum Press, 1977

12.

Palmer RH , Reilly MC : Individual and institutional variables which may serve as indicators of quality of medical care. Med Care 17:693-717, 1979

13.

Pauker SG : Coronary surgery: the use of decision analysis. Ann Intern Med 85:8-18, 1976

14.

Preston TA : Coronary Artery Surgery: A Critical Review. New York, Raven Press, 1977

15.

Principal Investigators of CASS and their Associates (Killip T, Fisher LD, Mock MB, eds): National Heart, Lung, and Blood Institute Coronary Artery Surgery Study (Cass). Circulation 63 (Suppl 1):I-1, 1981

16.

Rhee SO : Factors determining the quality of physician performance and patient care . Med Care 14:733-750, 1976

17.

Rhee SO : Relative importance of physicians' personal and situational characteristics for quality of patient care. J Health Soc Behav 17:10-15, 1977

18.

Roemer M. , Friedman J. : Doctors and Hospitals: Medical Staff Organization and Hospital Performance . Baltimore, Johns Hop-kins Press , 1971

19.

Scott WR , Forrest WH , Brown BW : Hospital structure and postoperative mortality and morbidity, in Shortell SM , Brown M (eds): Organizational Research in Hospitals. Chicago , Blue Cross Association, 1976, pp 72-89

20.

Shortell SM : Organization theory and health services delivery, in Shortell SM , Brown M (eds): Organizational Research in Hospitals. Chicago , Blue Cross Association, 1976, pp 1-12

21.

Shortell SM , Becker S. , Neuhauser D. : The effects of management practices on hospital efficiency and quality of care, in Shortell SM , Brown M (eds): Organizational Research in Hospitals. Chicago, Blue Cross Association , 1976, pp 90-107

22.

Shortell SM , Getzen T. : Measuring hospital medical staff organizational structure. Health Serv Res 14:97-110, 1979

23.

Shortell SM , LoGerfo JP: Hospital medical staff organization and quality of care:: results for myocardial infarction and appendectomy. Med Care 19:1041-1053, 1979

24.

Siegel S. : Nonparametric Statistics for the Behavioral Sciences. New York, McGraw-Hill, 1956, pp 202-213

25.

Weinstein MC , Fineberg HV , Elstein AS , et al: Clinical Decision Analysis. Philadelphia , W. B. Saunders, 1980

26.

Weinstein MC , Pliskin JS , Stason WB : Coronary artery bypass surgery: decision and policy analysis, in Bunker JP , Barnes BA , Mosteller F (eds): Costs, Risks, and Benefits of Surgery. New York, Oxford University Press, 1977 , pp 342-371

27.

Wennberg JE , Bunker JP , Barnes B. : The need for assessing the outcome of common medical practices. Annu Rev Public Health 1277-295, 1980