Imagine this: A 35-year-old woman comes to the doctor for vague chest pain without a clear cause.
A doctor puts her on a treadmill, a cheap and easy -- but not very accurate -- test for heart disease. The result comes back "mildly abnormal" but she has no risk factors for heart disease such as high cholesterol or high blood pressure.
"It's a dilemma: Do you do an angiogram?" said William Bezdek, a Bakersfield cardiologist. "It's not easy."
Cardiologists like Bezdek must weigh the risks of doing an angiography, which involves injecting dye into arteries to illuminate any heart blockages. An alternative would be to monitor the progression while exploring other possible sources of the pain, such as anxiety or heartburn.
If she lives in Bakersfield, chances are good the woman Bezdek described will get an angiography, an invasive, expensive yet highly accurate diagnostic test.
A recent study by Stanford professor Laurence Baker shows Bakersfield residents are 2.5 times more likely than the rest of the state to get an elective angiography. They're also about twice as likely to get an elective PCI, also called angioplasty, a procedure that usually places an artificial tube, or stent, into the heart arteries to open up the flow.
It's not surprising that Bakersfield has high rates of heart disease that would spike the number of angiographies and stents. But Baker adjusted the data to reflect the health of the population. Riverside and San Bernardino counties -- which also have high risks for heart disease -- were at or less than the state average in Baker's study. Even after leveling the playing field to compare all of California equally, the study shows Bakersfield has a much higher rate of elective invasive procedures.
Exactly why Bakersfield sees such high rates of these heart procedures is impossible to determine. But interviews with more than a dozen local healthcare workers revealed one common theme: Bakersfield patients often delay care, which exacerbates conditions and escalates treatment. Those dynamics could encourage local doctors to err on the side of more invasive treatments, creating a broader culture of aggressive medical care.
"It's always interesting to look and think about how the healthcare system could or should respond to these variations," said Baker, a professor of health research and policy. "I hope this will prompt people to talk to their colleagues, and talk about how to approach these cases."
PERCEPTIONS OF HEALTH
Bezdek said it makes sense to use diet, exercise and medications -- instead of invasive procedures -- if people are conscientious enough to actually take those steps. But in Bakersfield, he said, "that's a big if."
"Many people only see a doctor if they've been bucked off their horse and broken a leg," said Bezdek, who prefers to do his heart procedures at San Joaquin Community Hospital.
Dr. Jared Salvo, a cardiac electrophysiologist who did his training in Los Angeles, said he's noticed that many local patients lack primary care doctors and skip preventative care.
"A lot of people wait for something catastrophic to happen," he said.
Bakersfield nurse practitioner Blanche Glazier also pointed to a tendency of local residents to delay care -- more so than in other places where she's worked, such as Philadelphia and Tucson.
"We have a group of people for whom it's too late for anything other than intervention," she said. "They're in crisis before they get to the doctors."
Doctors also often question whether Bakersfield patients will take the tough steps necessary to improve their heart health.
"Patients don't show up for follow-ups," said Dr. Vinod Kumar, a cardiologist at The Heart Center. "They fill one bottle of medication and think they're set."
That back-seat approach to health could encourage doctors to be more aggressive, he said. Lifestyle modifications might be more desirable than putting in a stent. But if a patient isn't willing to do them, an invasive procedure may be worthwhile.
"It's a doctor's job to be more aggressive if you don't know if the patients will follow up," Kumar said.
He offered the example of a recent patient with 70 percent narrowing of a heart artery. He asked the patient to alter diet, exercise and reduce weight. Despite Kumar asking the patient to return regularly, the patient only came back once in six months. A short time after, the patient landed in the emergency room with a heart attack.
"I felt bad," Kumar said. "Maybe I should have put in a stent."
Dr. Todd Peterson, the medical director of the SJCH Chest Pain Center, said angiographies and stents aren't overdone in Bakersfield. But, he acknowledged that doctors' decisions are influenced by their perceptions of the community's health.
"It's like cutting to the chase," he said. "Why mess around with inconclusive tests? You don't want to miss anything. Every time we turn around there's heart disease."
In medicine, there is a tendency to be like one's peers, and local colleagues' approaches to care have a significant impact on doctor decisions, said Dr. Tommy Lee, a cardiologist who does many of his procedures at Bakersfield Memorial Hospital.
"Your practice has to be at a community standard," he said.
If the Bakersfield standard is higher on the aggressive spectrum, that means patients --even healthier ones --may be receiving different care than they would elsewhere in California.
Bakersfield has three hospitals that handle the vast majority of elective angiographies and stents: Bakersfield Heart Hospital, San Joaquin Community Hospital and Bakersfield Memorial Hospital. Baker did not break down the number of elective procedures by facility; the state doesn't track that either.
All the doctors interviewed for this story denied that finances play a role in their decisions about medical care. But these procedures can generate income -- for the doctor and facility.
Ronald Clyde, Memorial's director of cardiology services, said the hospital's billings hinge on the payer mix for such procedures. If someone doesn't have insurance for these procedures, the hospital will lose a lot of money. If they do, it makes up for it.
Cardiologist Bezdek said Medicare reimburses him just $420 in professional fees for a diagnostic angiography, and about $700 for a stent. They're not especially lucrative procedures, Bezdek said, "unless you're doing 10 to 20 a day."
In 2009, the median charge for one type of scheduled, inpatient PCI procedure ranged from about $44,000 to $58,000 at Bakersfield hospitals, according to the Office of Statewide Health Planning and Development.
At Bakersfield Heart Hospital, where some of the doctors are limited partners, income comes from both doctor fees and any share of hospital profits -- a fact that concerns Bezdek.
"If you own your own hospital, wouldn't that be in your interest to push patients?" he said. "To me, it's tough enough to decide an intervention purely on medical grounds without the economic pressures of having to support a hospital."
Still, Bezdek said he wasn't convinced economics drive up Bakersfield's high rates.
Dr. Denis Maddox, one of more than 40 partners at the Bakersfield Heart Hospital, said use of invasive procedures is appropriate. When asked why the adjusted data showed Bakersfield's numbers twice as high as the rest of the state, Maddox's tone changed and he rose from his seat.
"Our level of cardiac care is very high," he said, then left the room. "I am finished. I don't trust your motives."
Randy Rolfe, CEO of the Bakersfield Heart Hospital, said hospital officials compare their health outcomes with regional and national benchmarks and have found them "equal or better." "The Bakersfield Heart Hospital ranks in the top 10 percent of cardiac care in the country," he added.
A HISTORY OF STENTS
All of the cardiologists' assumptions and past experiences as well as the local culture of medicine come into play when a patient like Patrick Ellis comes to see them.
One recent afternoon, Ellis, 63, was recovering from a quadruple bypass surgery in a Memorial Hospital room. Ellis, a truck driver with a bald head and reddish-brown mustache, clutched a teddy bear over his chest to protect his recent incisions as he sat up in bed.
Ellis got his first angiography and stent about 13 years ago after experiencing chest pain. A year later, he got two elective stents that, he said, "cleared me up." Now, he has four stents.
Ellis can relate to doctors' opinions about patients delaying care. His colleague, who never saw a doctor, died from heart problems several months ago.
Over the past decade, his heart treatment has been aggressive, but, for him, that's been a good thing. He said he's optimistic his surgery will keep him going another 20 years.
For now, he's planning to take the doctor's advice and alter his lifestyle, eating healthier and exercising. But he admits that won't be easy. As time goes on, it's easy to slip back into old routines.
"At first, it scares the hell out of you," he said. "You get on a treadmill and you start to lose weight. But, then, you start to relax."