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J Am Coll Cardiol, 2004; 44:933-935, doi:10.1016/j.jacc.2004.07.003 © 2004 by the American College of Cardiology Foundation |
* Send correspondence to: Dr. Michael J. Wolk, 520 East 72nd Street, New York, New York 10021
But now we are operating in a wondrous era. We have developed excellent CV patient care protocols that capitalize on captured collective data and outcomes, in the belief that we can learn from each other without stumbling through the rocks ourselves.In the past 20 years, we have seen:
These advances—translated into wonderful care guidelines—come just in time, as the "perfect storm" of aging baby boomers and the growing epidemics of obesity and diabetes gather on the horizon. Yet, consistently applying this clinically helpful power "on the ground" is easier said than done. Study after study documents wide and pervasive gaps between what our College upholds as state-of-the-art, evidence-based care and the care actually delivered in clinical practice (1–6). This "voltage drop" from discovery to application threatens to deprive patients of the benefits of new treatments. We know that the American College of Cardiology/American Heart Association (ACC/AHA) guidelines are not being used as widely as would be optimal. Physicians report either a lack of guidelines awareness or, at times, even apathy in guidelines implementation as they juggle their fast-paced and highly pressured everyday practices (7,8). Regardless of the cause, the impact of underutilization of guidelines for effective care is real for patients, as evidenced in studies showingan increasingly strong relationship between use of evidence-based care practices and patient outcomes (9,10).
While underuse of proven therapies is a concern, so is the potential for overuse or misuse when services are ordered for reasons that are not in the best interest of patients. Unwarranted tests and therapies can unduly escalate costs to patients and society. The documentation on the overuse of tests or interventions in cardiology has been challenging because criteria for appropriateness are inherently subjective.Nevertheless, over the past decade there has been a marked increase in the growth of CV imaging services, particularly in the U.S.
Since 1996, the number of cardiac imaging procedures billed to Medicare has grown 9% per year, to 10.6 million in 2002—or more than one imaging test ordered for every four Medicare beneficiaries. Interpreting such data can be risky,however, because they do not necessarily mean that overuse has occurred. Instead, they may in fact demonstrate better care for the exploding population of patients with CV disease.
Other Medicare data, as well as the Dartmouth Atlas of Cardiovascular Health Care, show a striking variability in the use of cardiac procedures from one part of the U.S. to another. Paradoxically, the data also link states having higher Medicare spending to lower quality of care (11).Studies also have found that physicians trained in a given technique tend to order that procedure more often. True, this could indicate a potential for "self-referral," but it could also simply show that patients are being referred specifically to physicians with a known expertise.Finally, explicit reviews of indications for coronary revascularization procedures have shown relatively modest rates of obviously inappropriate care (12,13).
Another issue that threatens to tarnish this golden era of cardiology is the burgeoning cost of new technology. Medical innovations cannot improve patient care if society cannot afford to use them. This might seem to be a Malthusean prediction for future generations, butthe scarcity of financial resources is at hand. A recent editorial in the New England Journal of Medicine calculates that implantable defibrillators, left ventricular assist devices, and drug-eluting stents could add billions to an already strapped national budget (14). To stave off explicit rationing in medicine, cardiologists must strive to be mindful of medical costs. We must intentionally choose innovative modalities that will give us the most "bang for the buck." Stated simply, we need to ensure that every procedure we order for our patients is backed by solid, value-added care evidence.
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The role of the ACC in promoting quality |
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Beyond these efforts to ensure broader use of effective care, the College also has begun to tackle the challenging issue of procedural appropriateness directly, addressing potential overuse of diagnostic and therapeutic modalities. Appropriateness is clearly connected to clinical guidelines but has a level of complexity and detail that goes beyond their recommendations. It is the ACC's attempt to define "what to do," "when to do," and "how often to do" in the context of local care environments combined with patient and family preferences and values. Ideally, criteria for appropriatenesswould encompass "cost effective" and "benefit versus risk" analysis of available care alternatives. They should be simple, reliable, valid, and transparent. Answers to the overuse question will come through the aggressive promotion of patient care protocols and recommendations and by providing physicians with meaningful feedback on their care practices relative to national benchmarks.
Some may not see the importance of the College's efforts to address appropriateness. Some might argue that explicit guideline performance indicators can be divisive and prefer we not enter this arena. However, if we do not lead in this effort, others may set criteria that may not be wise either for us as physicians or for our patients.
Without this critically important initiative, we may become vulnerable to assertive third-party payers who may usurp our role and deny us our rightful voice in determining the best way to treat our patients. Attempts already are being made to control the rapid rise in costs for imaging and other services. Pre-certification, carve-outs of providers, reduction in payment, and mandatory lab accreditation have been instituted.
The College recognizes that failure to follow evidence-based best practices leads to less-than-optimal patient benefit through inefficient and ineffective use of resources. Although we have emphasized areas for improvement in patient care, we also recognize that the vast majority of cardiologists provide high-quality care. Our goal is to author and adopt the very best evidence-based guidelines and quality indicators in order to provide our members with as much guidance and as many tools necessary to help them in their daily practice. If we do not work collectively toward this result, others surely will step in and fill the void by monitoring our conduct, using cost-based algorithms rather than quality as the predominant driver. There is no rationale for permitting others to assume this function in our place.It is the role of our profession to self-monitor, critically review, and advance our concept of quality.We must be good stewards of the gifts—and responsibilities—that have been entrusted to us.
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This article has been cited by other articles:
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  R. C. Hendel Utilization Management of Cardiovascular Imaging: Pre-Certification and Appropriateness J. Am. Coll. Cardiol. Img., March 1, 2008; 1(2): 241 - 248. [Abstract] [Full Text] [PDF]
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 R. F. Redberg Computed Tomographic Angiography: More Than Just a Pretty Picture? J. Am. Coll. Cardiol., May 8, 2007; 49(18): 1827 - 1829. [Abstract] [Full Text] [PDF]
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 R. F. Redberg Evidence, Appropriateness, And Technology Assessment In Cardiology: A Case Study Of Computed Tomography Health Aff., January 1, 2007; 26(1): 86 - 95. [Abstract] [Full Text] [PDF]
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P. Douglas, A. E. Iskandrian, H. M. Krumholz, L. Gillam, R. Hendel, J. Jollis, E. Peterson, J. Chen, F. Masoudi, E. Mohler III, et al. Achieving Quality in Cardiovascular Imaging: Proceedings From the American College of Cardiology-Duke University Medical Center Think Tank on Quality in Cardiovascular Imaging J. Am. Coll. Cardiol., November 21, 2006; 48(10): 2141 - 2151. [Full Text] [PDF]
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P. S. Douglas, M. J. Wolk, R. Brindis, and R. C. Hendel President's Page: Appropriateness Criteria: Breaking New Ground J. Am. Coll. Cardiol., December 6, 2005; 46(11): 2143 - 2144. [Full Text] [PDF]
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 H. V. Anderson, R. E. Shaw, R. G. Brindis, L. W. Klein, C. R. McKay, M. A. Kutcher, R. J. Krone, M. J. Wolk, S. C. Smith Jr, and W. S. Weintraub Relationship Between Procedure Indications and Outcomes of Percutaneous Coronary Interventions by American College of Cardiology/American Heart Association Task Force Guidelines Circulation, November 1, 2005; 112(18): 2786 - 2791. [Abstract] [Full Text] [PDF]
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M. R. Patel, J. A. Spertus, R. G. Brindis, R. C. Hendel, P. S. Douglas, E. D. Peterson, M. J. Wolk, J. M. Allen, and I. E. Raskin ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging J. Am. Coll. Cardiol., October 18, 2005; 46(8): 1606 - 1613. [Full Text] [PDF]
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M. J. Wolk, R. L. Popp, S. C. Smith Jr, and A. N. DeMaria President's page: The trust imperative: Ethical choice always puts patient first J. Am. Coll. Cardiol., October 19, 2004; 44(8): 1709 - 1711. [Full Text] [PDF]
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