Interventional Cardiology has an Image Problem
Washington state has convened a Health Technology Assessment program to evaluate for therapies which are deemed insufficiently cost-effective for state-sponsored insurance programs to cover. They decided to address drug-eluting stents (as opposed to bare metal stents) and I was invited to be a consultant for this process, along with several other physicians, most of whom were not interventional cardiologists. As we discussed the relative merits of drug-eluting stents versus bare metal stents for a variety of conditions, a consistent theme kept cropping up from those who were not interventional cardiologists. Frequent comments were made to the effect that there were too many inappropriate coronary interventions being done, with the implication that this HTA process needed to assist in reigning this in (despite the fact that our task was not to assess appropriate indications for coronary intervention, simply the relative cost-effectiveness of drug-eluting stents over bare metal stents). It became apparent to me that interventional cardiology has an image problem, which is threatening to impede our ability to decide for ourselves what is the optimal treatment for our patients, due to the effect of imposed outside interests. Our discipline has come to be looked at by many — within the medical community and the media — as self-serving individuals who cannot regulate themselves. I began to wonder — is there really this epidemic of inappropriate coronary interventions being done (the so-called 50%, asymptomatic lesion), or is this an “urban legend”, wherein ‘someone knew of friend of a cousin of a nurse’s brother, in a hospital in another state, wherein there clearly was a factory of inappropriate angioplasties.’ I work in a somewhat cloistered environment of an academic institution, so perhaps I am sheltered from this activity. However, I not uncommonly find the opportunity to be in other hospitals’ cath labs for a variety of reasons, and I am invariably struck by the professionalism and commitment to patient-care in each of these places. So even outside of my institution, I do not personally see this type of self-centered practice described by my non-interventional colleagues as being so rampant.
My question to anyone reading this blog is this:
Is there an epidemic of inappropriate coronary interventions being done, for economic gain?
Do the interventional cardiologists reading this blog see this practice among their competition, among their colleagues, or within themselves? Or is this perception a result of media reporting of various “negative” studies , such as COURAGE or FAME? These studies, which suggested that we could fine tune who is most likely to benefit from a coronary angioplasty procedure beyond simply the ”occulostenotic reflex”, do not indicate that angioplasties are being done inappropriately for economic gain, but seem to be used as justification for those beliefs anyway.
My next question is this:
If there is rampant performance of inappropriate coronary interventions, how can we regulate ourselves? Certainly, as the Washington state HTA process has shown, outside interests will attempt to regulate us, due to the perception that we are not regulating ourselves, and we will lose control over our destiny. Alternatively, if the “inappropriate angioplasty” is more of an urban legend, what can we (the interventional cardiology community) do to ensure that we are being perceived as being focused on patient care, rather than economic gain? Otherwise, people who are less knowledgeable about coronary artery disease management will be making decisions about our patient’s care.
Steven L. Goldberg, MD is the Director of the Cardiac Catheterization Laboratory at the University of Washington Medical Center in Seattle, where he is a Clinical Associate Professor of Medicine. He also serves as the Chief Clinical Officer for Cardiac Dimensions, Inc., a small biotech company in Kirkland, Washington.
I was surprised at how quickly and forcibly the media jumped on the COURAGE and FAME studies. I believe this is a reflection of a general movement in the US to rein in healthcare costs.
Cardiology is the source of a large portion of healthcare costs with some of the most expensive procedures in medicine (bypass surgery, ICD implants, DES implants).
And the fee-for-service approach is seen negatively by most people looking to reduce healthcare spending as it seems counter-intuitive.
I believe the best step invasive cardiologists can take is to develop a better healthcare delivery methodology - one that does not provide all financial reward based on number of procedures performed. Perhaps hospitals employing all physicians with privleges at their facility, paying at least half of the physicians' income and collecting a percentage of the physician fees from Medicare and insurance companies would help.
Until the large financial incentive to perform procedures is removed, physicians will never be trusted by the community.
Reply to this comment »I agree ,interventional cardiologists have not only a image problem some of them have an attitude problem * as well !They looked down on the clinical cardiologist for more than a decade .Now they are in the receving end .
As we know , it is very difficult to self regulate (Like our financial institutions and Wall street).So there is nothing wrong if they are forced to change for the better by external forces.
*Excuse me if I sounded little harsh but I have felt this to be genuine.
Please read my blog which has somewhat related to this topic.
www.drsvenkatesan.com
www.drsvenkatesan.wordpress.com
1 Who is an interventional cardiologist ?
http://drsvenkatesan.wordpress.com/2009/08/07/who-is-a-interventional-ca...
2 . How to humiliate medical therapy for CAD ! Learn how COURAGE and OAT trials were disgraced by the mainstream interventional cardiology community
http://drsvenkatesan.wordpress.com/2009/09/25/how-to-humiliate-medical-t...
Reply to this comment »I work in a community hospital in San Diego and we do approximately 550 PCI's /year. I worked in the cath lab for 12 years. I can honestly say that I do not feel interventionalists are performing unnecessary PCI's. Our MD's are very knowledgeable about guidelines and stratifying pts so it will decrease unnecessary procedures. I do feel however that with increased use of IVUS/ Flow and pressures wire technology you will see more PCI's on lesions that angiographically do not look that severe but when you IVUS/or measure flows or pressures the stenosis is significant and therefore an intervention is done. This information is now included in the ACC PCI national database. For any lesion with a stenosis 40-70% by dx cath, it asks if IVUS was done and or FFR and what those ratio's were(starting in July 09 Version 4). My experience in San Diego is that the cardiologists do everything in their power to present pts with all the options and treatments available, the pro's and cons of each. We have bi-monthly cath conferences and present pts and get surgeons and cardiologists input so the best decision can be made for each pt. It is not uncommon to hear the suggestion that the best treatment would be to manage the pts medically and see how they feel, if their symptoms improve etc before going the invasive route. I don't believe that money is the motivating factor in determining a pts treatment plan. Also the pts and their families are very involved in this decision. Md's discuss the need for plavix therapy and timeframe and cost and this is added to the equation in the decision. As far as bare metal stents verses des...it is very clear that des are superior to bms in regards to restenosis rates. When talking about cost...one should calculate the cost of repeat procedures for restenosis and sometimes go on to CABG in the case of BMS. Our MDS present pts with the risk and benefits of each stent. I think if you placed a BMS in a pt who had a lesion which data shows clearly does better with DES, and the pt gets restenosis what do you say to the pt when they want to know why you did not place a DES? I think BMS definitely have a place in PCI...large vessels, lesions that are not proximal or at bifurcations, the length of the lesion etc. I truly feel that the majority of MD's really do want to do what is best for their pt....of course there are always some that money may be the motivating factor but if more of their peers would give feedback to these individuals it would not be done as frequently. If staff in the lab are uncomfortable with a procedure that was done we always are encouraged to talk to the manager and the Cath Lab Director so the case can be reviewed. Also there is peer review committee's who also over see this. And finally, (at least in CA) physicians actually get less money the more procedures they do.....they would be doing less procedures if money was their motivator. Thanks for your time
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