Clinical Ambiguity and Conflicts of Interest in Interventional Cardiology Decision-Making

Manufacturing & Service Operations Management, Forthcoming

38 Pages Posted: 17 Jul 2020 Last revised: 19 Jan 2021

See all articles by Tinglong Dai

Tinglong Dai

Johns Hopkins University - Carey Business School

Xiaofang Wang

Renmin University of China

Chao-Wei Hwang

Johns Hopkins University - School of Medicine

Date Written: January 18, 2021


Problem Definition: Among the most vexing issues in the U.S. healthcare ecosystem is inappropriate usage 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: 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.

Keywords: Clinical ambiguity, conflicts of interest, interventional cardiology decision-making, percutaneous coronary intervention (PCI), advanced intracoronary testing, fractional flow reserve (FFR)

JEL Classification: I11, C44, D04

Suggested Citation

Dai, Tinglong and Wang, Xiaofang and Hwang, Chao-Wei, Clinical Ambiguity and Conflicts of Interest in Interventional Cardiology Decision-Making (January 18, 2021). Manufacturing & Service Operations Management, Forthcoming, Available at SSRN: or

Tinglong Dai (Contact Author)

Johns Hopkins University - Carey Business School ( email )

100 International Drive
Baltimore, MD 21202
United States


Xiaofang Wang

Renmin University of China

59 Zhongguancun St
Haidian Qu
Beijing, Beijing 100872

Chao-Wei Hwang

Johns Hopkins University - School of Medicine ( email )

733 North Broadway
Suite G-49
Baltimore, MD 21205-2196
United States

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