By Kartik Mani M.B.B.S.*
If there was a single theme at the SCAI 2012 Scientific Sessions, it would have to be appropriateness.
From the classrooms to the hallways, at the podium and during the Q&A, the Appropriate Use Criteria (AUC) dominated our discussion and debate.
The professional societies, including SCAI, have created these guidelines derived formulae for a number of reasons, not the least of which is to support us in our struggles with payors, legislators, and media.
In theory, the AUC will help standardize care, so that whether in a university setting in the northeast or in a small community hospital in the southwest, patients can expect a similar standard of care because everyone is following the same rule-book. And, on its face, it makes sense to create clear standards for performing or withholding a diagnostic/therapeutic approach in clinical practice.
As the SCAI representative to one of the multi-society AUC review panels, I became convinced the AUC were the right approach. Sitting through nearly 18 hours of grueling debate with other cardiology specialists, internists and payors, I believed this consensus approach would yield clear directions for clinical practice that would help simplify clinical decision-making at all levels while simultaneously streamlining delivery and reimbursement of care and protecting the system from fraud and abuse.
And so I was truly surprised by the disparity in my colleagues’ reactions to the AUC. In fact, I was stunned when an unscientific poll of SCAI 2012 attendees revealed, in almost all instances, equal proportions of strident protest, meek acceptance or complete befuddlement at the whole concept of AUC.
One example played out during an interactive session moderated by SCAI 2012 Program Co-director Kenneth Rosenfield, M.D., FSCAI, and Samir Pancholy, M.D., FSCAI. The case featured a 54-year-old male construction worker who is a smoker with Rutherford 3 claudication and a completely occluded ipsilateral superficial femoral artery, on no medical therapy with no prior trial of exercise or smoking cessation. After erudite discussion, audience polling on a peripheral interventional approach revealed a vote split three ways: 33 percent for Appropriate; 33 percent, Inappropriate; and 33 percent, Uncertain.
A perfect lack of consensus on a seemingly straightforward case.
How can this be? On the surface, invasive management and possible intervention appear Inappropriate. This is what the guidelines and the AUC would say because a peripheral intervention will not preserve the patient’s limb and may or may not provide lasting relief to a smoker with diffuse atherosclerotic disease.
But think about this case more pragmatically. In this patient’s line of work in today’s economy, PAD may predispose a construction worker to be less physically active and more likely to lose employment. As a young smoker, he is more likely to be lost to both follow-up and possible secondary prevention strategies.
But in the interest of upholding the academic principle of exercise first, smoking cessation next and finally, if all else fails, interventional therapy, this man may find himself unemployed, more likely to be more sedentary and thus, more obese and at greater risk for cardiovascular mortality and morbidity. Or if, despite the AUC, we offer him the Inappropriate intervention – and in sense “reward his bad behavior,” namely smoking – will he be more likely to exercise because it won’t hurt, more likely to quit smoking because he doesn’t want to have another procedure, and more likely to adopt a healthier lifestyle?
In this case, would adherence to the AUC help this man or hurt him? Would society benefit by saving the cost of the intervention, or would it lose out on workforce productivity, purchasing power, and increased healthcare expenditure on his long-term illness? Or would disregarding the AUC for patients such as this one encourage abuse of the system by opportunists, including physicians, patients, and other groups who benefit from wide use of invasive procedures?
This is one case, somewhat oversimplified to make a point. Despite what I personally might prefer for this patient, I still believe the AUC approach is sorely needed. If as a profession we do not develop AUC to shield ourselves from oncoming regulatory assault, the threat to our existence as interventionalists will become reality. Then who would suffer most? Ultimately, it would be our patients. Regardless of these cases, we will be needed; you still must treat STEMIs and CLI. Despite the best intentions of the AUC architects, in many situations the AUC cannot encompass the multiple layers and dimensions involved in individual cases. But they are the yardsticks on which you and I will be measured, and so we must work with them as best we can. When I arrived at SCAI 2012, I would have scored the concept of the AUC as Appropriate. After attending SCAI 2012, with its rigorous and eye-opening debates, I am not ready to label them Inappropriate but I am leaning toward a solid Uncertain. n
*Dr. Mani is chief of the Division of Internal Medicine at Mercy Medical Center in Roseburg, OR. He is a Board-certified interventional cardiologist and certified device specialist and an active SCAI member who participates in the Early-Career, eSCAI, Structural Heart Disease, and Advocacy committees.
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