Drug-Eluting Stents in New York State: Utilization, Disparities, Cost, Outcomes and Practice Variation

Coronary heart disease (CHD) has been the leading cause of death in both men and women in the United States for over 80 years and is a major cause of disability. Innovative medical technologies have been adopted continuously in treating CHD. The drug-eluting stent (DES), the newest medical device in percutaneous coronary intervention (PCI), has been adopted quickly since the Food and Drug Administration (FDA)'s approval in 2003. But, disparities and practice variations in DES use were reported during the initial years. Evidence suggests that both institutional and physician level factors can affect practice pattern. The safety of DES use was called into question in 2006. However, few studies have been conducted to answer the following questions: What is the relationship between DES adoption and revascularization pattern change? How did the disparity in DES use respond to the DES safety concern? What is the relationship between DES adoption and hospitalization cost for PCI procedures? What is the relationship between DES adoption and patient outcomes? How do institutional and physician level factors explain DES adoption?;To answer above questions, this dissertation uses three preexisting data sources (New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS), 2000 Census File, and New York State Hospital Profile) and a survey of New York State interventional cardiologists. Conceptual models are applied, and statistical models are used to test theory-derived hypotheses. This study finds that DES adoption changed the coronary revascularization utilization pattern. Practice variation in DES use was found. DES utilization profiles were affected by the DES safety concern and they differed by race, payer, hospital type and region. Racial, payer, and regional disparities emerged and changed during the course of the DES safety concern development. To the best knowledge of the author, this study is the first to report "re-adoption" disparity following the safety concern of a new medical technology adoption. As to the hospitalization cost of primary isolated PCI procedures, huge variation across hospitals was found. As to the outcomes of primary isolated PCI procedures, no significant difference in in-hospital death was detected between the DES group and the BMS group. Both hospital behavior theory and regulatory focus theory had explanatory power in explaining DES use. Hospital behavior theory was found to have explanatory power when DES utilization remained stable whereas regulatory focus theory was found to have explanatory power when DES utilization experienced dramatic changes. Physicians with stronger prevention focus were less likely to adopt DES when DES was introduced to the market as the newest technology whereas physicians with stronger promotion focus were more likely to stick with DES use when the DES safety concern developed.;The findings from this study suggest policy implications in allocating financial, material, and personnel resources at hospitals and medical education and training systems. To mitigate disparities, attention should be given to black patients, self pay patients during the periods of safety concern development and technology re-adoption. Better quality of care and lower hospitalization cost in revascularization care might be achieved by reforming hospital's structure and management. Actionable strategies based on hospital behavior theory and regulatory focus theory can better motivate hospitals and physicians to provide optimal quality of care to patients.