Our second objective was to analyze whether certain physicia

Our second objective was to analyze whether certain physician characteristics may play a role in these diagnostic and therapeutic decisions. In contrast to what might have been expected, younger cardiologists were not more aggressive than older ones. In fact, if anything, the reverse trend was observed, with older cardiologists more likely to stop β-blockers before performing exercise testing, more likely to combine antiplatelet and anticoagulant agents, and more likely to prescribe coronary angiography directly in the cases of recurrent congo red in elderly patients with known CAD. One possible explanation for this latter finding might be the fact that this strategy was more prevalent in the past, at a time when non-invasive tests were not so widely used, but possibly also when it was believed (before the results of randomized clinical trials; Boden et al., 2007) that myocardial revascularization might improve survival in stable patients. Female physicians appeared more reluctant to use DOAs, and more prone to prescribe β-blockers as a routine preventive medication in asymptomatic patients after CABG; this might be interpreted overall as a more cautious attitude. In contrast, academic cardiologists were more likely to adopt new drug approaches, such as DOAs, or newer attitudes such as prescribing anticoagulants alone rather than dual antithrombotic therapy when anticoagulants were needed. The results of trials comparing DOAs and vitamin K antagonists are relatively recent, as are the guidelines (2010–2011) suggesting that oral anticoagulation alone may be a safe option in stable CAD (Camm et al., 2010; Fuster et al., 2011), and these conclusions may well have been more readily adopted by the academic community. One could have hypothesized that cardiologists in private practice may have specific practice patterns, related to the personal financial impact of test prescription. This was however not so clear-cut; in virtually all respects, private cardiologists gave similar answers to those of cardiologists working in hospitals. Similarly, one might have expected to observe a more aggressive approach (tendency toward using more tests and coronary angiographies) by interventional cardiologists. Again there was no indication for this, with the one possible exception of their more frequent decision to go directly to coronary angiography in the cases of recurrent angina in patients with known CAD; on the other hand, interventional cardiologists were less likely to discontinue β-blockers before prescribing an exercise test. Overall, the type of medical practice had relatively little influence on management patterns. Other than the fact that continuous medical education programs for both private and public sector cardiologists are similar, this could be partly explained by the new system of funding of public hospitals in France (“tarification à l\'activité”), which has been in place since 2007 and actually encourages physicians to use tests or procedures (typically, coronary angiography) that are highly valued in terms of state funding to their institutions. In other words, the current health system in France encourages physicians to use tests/procedures rather than simply provide clinical care to their patients: private cardiologists earn more if they perform such tests, while the institutions employing public-sector cardiologists benefit directly from the use of these tests.
Author Contributions
Conflicts of Interest CB: travel grants from MSD-Schering, Boehringer-Ingelheim, and Servier. GL: fees for lectures or consulting from Astra-Zeneca, Bristol-Myers Squibb, Daiichi-Sankyo, and Eli-Lilly. NL: research grant from Pfizer and fees for lectures or consulting from Actelion, Astra-Zeneca, Bayer, Bristol-Myers Squibb, GlaxoSmithKline, MSD-Schering, Novartis, Pfizer, Sanofi-Aventis and Servier. ND: research grants from Amgen, Astra-Zeneca, Bayer, Daiichi-Sankyo, Eli-Lilly, GSK, Merck, Novartis, Pfizer, Sanofi-Aventis, Servier, and The Medicines Company and fees for lectures or consulting from Amgen, AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer-Ingelheim, Daiichi-Sankyo, Eli-Lilly, GlaxoSmithKline, MSD-Schering, Novartis, Novo-Nordisk, Pfizer, Roche, Sanofi-Aventis, Servier and The Medicines Company.