• SCAI President’s Response to US News & World Report Articles on Cardiac Procedures

    February 11, 2015

    A package of articles in today’s US News & World Report, “Are Doctors Exposing Heart Patients to Unnecessary Cardiac Procedures?” raises pointed questions about the number and variation in rates of cardiac catheterizations for procedures such as angioplasty and stent implantation performed in centers outside major urban areas across the country. Citing Medicare and billing data, it highlights the record of a single practitioner in rural Louisiana who performed a high number of procedures, though it clearly states he hasn’t been accused of wrongdoing.

    SCAI believes in transparency and public reporting when done thoughtfully, as well as in robust public discussion of issues such as those raised in the article. Our mission is "to promote excellence in invasive and interventional cardiovascular medicine through physician education and representation, and the advancement of quality standards to enhance patient care." Although likely well-intentioned, US News’ broad and unfiltered presentation of Medicare Big Data for alleged patterns of abuse does not meaningfully contribute to advancing quality standards or enhancing patient care.

    The article’s listing of Medicare payments to more than 300 individual physicians, including their procedural volume and aggregate payments, offers little insight into the reason for the procedures, the complexity of the procedures, or the outcomes experienced by their patients. While each of our members may monitor his or her procedural volume, it is only one minor variable of the many complex measures of quality and appropriateness of care. Singling out an individual physician who has not been accused of any wrongdoing and broadly listing hundreds of cardiologists’ names and raw data with no context is unfair to most of these physicians and the patients who benefit from their care.

    Readers are left to assume there are no established practice standards, which is absolutely untrue. Most “high-volume” operators sustain a heavy procedural load because of local referral patterns. This in itself may be a measure of quality care, as it likely reflects their colleagues’ confidence in the operators’ ability to provide the best care for their patients. Additionally, volume alone does not take into consideration local issues of available workforce or how heart disease incidence, risk factors and patient adherence to healthy lifestyle recommendations vary from region to region. The American Heart Association Heart Disease and Stroke Statistics Book clearly demonstrates regional disparities in the prevalence of cardiovascular disease and event rates, which may influence utilization for interventional cardiologists.

    Some factual correction is also required as it pertains to this article: (1) the complication rate for PCI is not 5 percent; it is closer to 1 percent; and (2) medical therapy is not always the best therapy for stable patients – the COURAGE study, headed by Dr. Boden and referenced in the article, enrolled only 1 in 10 qualifying patients, so it is difficult to generalize these findings.

    These are complex issues, as the article acknowledges. For example, countless studies have proven percutaneous coronary intervention (PCI) significantly reduces mortality in the setting of MI and enhances patient quality of life. Further studies examining which stable ischemic heart disease patients benefit most from PCI are forthcoming.  As medical science has evolved in cardiovascular care, our practices change, as evidenced by a significant decline in elective PCI volume since 2003.

    We agree with SCAI Trustee Ralph Brindis, MD, MPH, FSCAI, who is quoted in the article:  We interventionalists should be aware of our individual procedure volumes as well as indications, complications, and outcomes. Most, if not all, catheterization laboratory quality improvement programs, which are an integral component of all interventional programs, do such.  Doing so helps advance our patients’ well-being and will help us tackle the many questions that are emerging in the field today. But let’s not forget that SCAI and our peer organizations spearheaded a large number of major quality initiatives over the past decade, including development of guidelines, appropriate use criteria, quality improvement and decision-support tools, ACE quality review and accreditation, and the creation of national registries of cardiovascular cases and outcomes. Many of us already embrace these opportunities.  If you have not already done so, I strongly encourage you to use these tools that are designed for you. This is SCAI’s mission and how we can all enhance patient care.

    Contact me at president@SCAI.org.

    Best regards,

     

    Charlie Chambers, MD, FSCAI
    SCAI President, 2014-15