HOME SUBSCRIPTIONS CURRENT ISSUE PAST ISSUES CARDIOSOURCE SEARCH HELP FEEDBACK		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ritchie, J. L. Articles by Wann, L. S. Search for Related Content PubMed PubMed Citation Articles by Ritchie, J. L. Articles by Wann, L. S.

TASK FORCE

Task force 4: Appropriate clinical care and issues of "self-referral"

	Introduction

Top Introduction Ensuring appropriate use of... Direct-to-consumer advertising... Cardiovascular specialty... Legal issues in self-referral Overview and summary References

For the purposes of this document, "self-referral" occurs when a physician recommends a patient intervention from which the physician may benefit personally. Such recommendations usually facilitate the provision of efficient, effective, and high-quality care, but may also afford the potential for abuse. As former JACC Editor-in-Chief William Parmley stated so clearly: "At issue is the question of intent; if the intent is to provide excellent medical care, the practice is laudable. If the intent is to subjugate medical decision-making, then the practice is unethical" (2). Those few physicians who are publicized for violating our trust do not reflect the rank and file of cardiovascular specialists.

The cardiovascular specialist's primary duty is to the patient. His or her role is to promote patient welfare in an increasingly complex health care environment, one that has been made even more complex by the anti-kickback statutes and Stark laws (see the following sections). Having entered into a physician-patient relationship, physicians must counsel their patients regardless of individual financial or medical care delivery system considerations or other factors, such as socio-economic status, race, gender, or sexual orientation (3). The physician's clinical judgment must not be influenced by financial incentives from a fee-for-service system or disincentives from a capitated care system. Recommendations should be made based only on medical merit (4,5). Physicians must also contribute to the responsible stewardship of health care resources.

Growth and geographic variation in cardiac procedures.   The use of cardiac procedures in the U.S. is increasing over time. Figure 1 displays changes in the number of diagnostic cardiac procedures performed for Medicare patients between 1994and 2002. Office-based procedures account for much of the rise in nuclear and echocardiographic testing. Many factors, such as the aging of the population, the epidemic of diabetes and obesity, advances in technology, and new therapies, may partially drive these increases. Studies have demonstrated marked geographic variations in the use of both invasive and non-invasive cardiac procedures (6–10). The exact cause for geographic variation in procedure use remains elusive. Similar studies have found a linear relationship between the availability of cardiovascular diagnostic equipment in a given region and the use of such equipment. The strongest predictor of catheterization in a study of acute myocardial infarction was the availability of onsite angiographic facilities (8). Other studies have confirmed this relationship across a variety of health care practice settings. More recent studies have demonstrated similar correlations between the availability and use of nuclear equipment in a given area and the additional correlation between rates of cardiac catheterization and coronary revascularization (9). These data suggest that the use of non-invasive diagnostic technologies appears to have a multiplying effect on subsequent cardiac resource utilization.

View larger version (42K): [in this window] [in a new window]   Figure 1 Number of cardiovascular imaging procedures among Medicare patients, 1994 to 2002.

	Ensuring appropriate use of procedures

Top Introduction Ensuring appropriate use of... Direct-to-consumer advertising... Cardiovascular specialty... Legal issues in self-referral Overview and summary References

 
Various options exist for managing potential conflicts of interest regarding self-referral in clinical practice. In-office/in-lab procedures performed in accordance with ACC/AHA guidelines by a physician who is competent in the performance of the procedure simply reflects efficiency and the appropriate standard of care. Physician ownership of medical equipment, especially high-cost, high-revenue equipment, is a complex professional issue. In all cases, the ownership should be fully disclosed to the patient as described in the American Medical Association (AMA) Code of Medical Ethics(16). The core question is whether clinical decisions are in the patient's interest or influenced by potential personal gain by the physician owner. Although this potential conflict exists, these arrangements may improve access and quality of care for patients. In general, the following approaches should optimize care and reduce concerns about inappropriate self-referral:

• use of evidence-based guidelines

• physician and laboratory credentialing

• periodic case conferences

• oversight/review processes

• consultation with other providers

• full discussion with the patient regarding risks, benefit, alternatives, and the option for a second opinion

• disclosure/transparency of ownership

Utilization of ACC/AHA practice guidelines and clinical competence statements.   The cardiovascular community has access toextensive and disease-specific treatment guidelines to inform diagnosis and treatment decisions. These joint ACC/AHA documents include comprehensive guidelines for the management of most major cardiovascular diseases, including acute coronary syndromes, stable coronary artery disease, congestive heart failure, valvular heart disease, atrial fibrillation, supraventricular arrhythmias, and preoperative evaluation for noncardiac surgery. Additional guidelines for specific therapeutic interventions are available including percutaneous coronary intervention and coronary artery bypass surgery. Utilization guidelines for most technical procedures have been developed by the ACCF, the AHA, and other subspecialty societies. These include guidelines for echocardiography, electrocardiography, ambulatory electrocardiographic monitoring, cardiac catheterization, nuclear studies, pacer-defibrillator implantation, and exercise testing.

Where appropriate, guideline-writing groups include representatives from many specialties, including cardiovascular surgery, internal medicine, family practice, emergency medicine, and anesthesiology. These guidelines are easily accessed, either in full text or in an executive summary form on both the ACCF and the AHA web sites (www.acc.org and www.americanheart.org) and can be downloaded to handheld computers. The guidelines are reviewed at least yearly and updated as needed. Thus, current evidence-based information about best practices is now available to physician, payer, and patient alike, providing a powerful resource for appropriate evidence-based care (17,18). These guidelines also provide recommendations for the frequency of performance of office procedures and allow responsible parties to play a key role in understanding the need for testing. Specific recommendations for the performance of diagnostic and therapeutic interventions are thus clearly defined and are available to the entire health care community; these broaden participation in determining when and in whom to carry out patient interventions.

The ACC/AHA guidelines form the basis for three additional instruments of great value in providing continuous quality improvement. Systems-based approaches such as the ACCF's "Guidelines Applied in Practice" and the AHA's "Get With the Guidelines" programs have been shown to enhance effective application and improve outcomes (19). In addition, performance measurements are being developed jointly by the ACCF and the AHA for performance improvement and appropriateness of care. Closely related are issues of physician training and competence in performing specific procedures. Practitioners performing procedures on their own patients or by referral should achieve certification of adequate training and maintenance of competence over time. The ACCF, the AHA, the American Board of Internal Medicine, and subspecialty groups have developed a series of documents that detail the appropriate training and experience for competence in a wide variety of cardiovascular procedures (20).

Laboratory oversight.   Appropriate oversight by physician laboratory directors is another approach to monitoring self-referral while broadening responsibility and encouraging proficiency in the performance of procedures. Regular review by physician directors of catheterization, echocardiography, nuclear, and other laboratories is important in ascertaining that indications for patient referral, procedural quality, and outcomes all are satisfactory. Additionally, they ensure that caseload or other factors do not drive clinically inappropriate laboratory utilization.

Participation in laboratory databases is essential, with regular review and comparison to databases such as the ACC National Cardiovascular Data Registry^TM (21), which can be used for benchmarking of individuals, groups, or hospitals. While it is often difficult to determine the appropriateness of any single procedure in any single patient, patterns of "diagnostic yield" from these tests can be helpful. For example, a laboratory whose rate of finding non-occlusive coronary disease that is significantly higher than one's peers may need to review its selection criteria and threshold for testing. Professional review groups consisting of experts from outside of the geographic region also can be employed when local review is impractical. Diagnostic laboratories should participate in accreditation and credentialing.

Broadening health care responsibility.   Given that the potential for real or unconscious bias can be driven by financial conflicts, another approach to avoiding such bias is to involve other physicians without any financial stakes in either clinical case-management conferences or conjoint patient management.

Although the vast majority of care decisions are made on an individual physician-patient basis, the potential for inappropriate self-referral may be moderated by employing clinical case conferences. Such meetings may include invasive and non-invasive cardiologists, primary care providers, independent cardiovascular surgeons, cardiac care associates, and others, thus broadening the input into patient management decisions.

Another approach for responsibility sharing involves "partnerships in care," wherein patients are cared for conjointly by their primary care provider and a cardiovascular specialist. In this care model, it is implicit that the cardiologist will perform specialized diagnostic and therapeutic procedures, with input from the referring and consulting physician, as well as from the informed patient.

Physicians are often viewed by their patients as having ultimate authority in health care decisions. Therefore, physicians must present the patient with a comprehensive discussion of treatment alternatives, including the option to do nothing, along with the relative risks and benefits of each alternative course. Whenever doubt exists on the part of the patient or the physician, there should be the opportunity to seek additional opinions. For example, patients proposed for multivessel angioplasty should generally be told of surgery as an alternative and have the opportunity to consult a cardiovascular surgeon. For those patients who cannot or will not participate in a discussion of care alternatives, it may be appropriate to involve other family members, friends, spiritual advisors, and patient advocates in decision making. In summary:

• The ACC/AHA guidelines are available for most cardiovascular conditions and for diagnostic and therapeutic procedures, and are readily accessible to physicians and patients on the ACC and the AHA web sites.

• Physician compliance with ACC/AHA guidelines for management of patients with cardiovascular disease represents appropriate care in the majority of cases, and such compliance should reduce concerns about self-referral by cardiovascular practitioners.

• Procedural oversight by a professional laboratory director and laboratory accreditation are both essential.

• Both procedural training and the credentialing of physicians, technicians, and other health care providers are critical to good care.

• Involving other health care providers in medical care decisions, such as cardiovascular surgeons and primary care providers, limits bias.

	Direct-to-consumer advertising and screening

Top Introduction Ensuring appropriate use of... Direct-to-consumer advertising... Cardiovascular specialty... Legal issues in self-referral Overview and summary References

 
Advertising of health-related services and products has grown significantly in recent years. Direct-to-consumer (DTC) advertising appears to be well entrenched and has been legal for pharmaceuticals since the early 1970s. More recently, advertising in the public media has grown rapidly for medical devices, diagnostic testing (such as computed tomography-based coronary artery calcium screening or cholesterol screening), and for many non-cardiac or related procedures. Sometimes performed in shopping malls or church parking lots, these activities have raised a variety of ethical concerns for the medical profession. At question is the propriety of such DTC advertising, physician ownership or investment in such enterprises, concern about patient referral by a physician to a facility in which he or she is an owner or investor, and the value of such screening in promoting the public health.

Physician advertising is now recognized as legal under the provisions of Section 5 of the Federal Trade Commission Act. Regulations were clarified extensively by the Food and Drug Administration (FDA) in 1997, including such language as the requirement for "adequate provision: side effects, contraindications, and effectiveness—this should include either reference to a toll-free phone number, a referral to a physician or pharmacist, a referral to a print advertisement containing a summary of risk, and a web site." No such guidelines exist for device manufacturers for diagnostic testing; in fact, the FDA has opposed some of the diagnostic screening and testing advertisements (22,23).

Both the AMA and the American College of Physicians have reviewed these issues and published similar guidelines (4,5). These guidelines state that such advertisements "shall not be misleading because of the omission of necessary material information, shall not contain any false or misleading statement, or shall not otherwise operate to deceive." The AMA states that advertisements should "communicate the information contained therein to the public in a readily comprehensible manner" (22,23). Further, "the key issue, however, is whether advertising or publicity regardless of format or content is true and not materially misleading." It thus seems clear that advertising per se is professionally accepted and legal, and the issues are those of appropriate content and disclosure.

Guidelines similar to those for DTC pharmaceutical advertisements seem appropriate and in part have been proposed by the AMA for DTC advertising of diagnostic testing. Where cardiovascular testing is involved, professional societies such as the ACCF and the AHA should assume a leadership role in defining these guidelines at the policy level rather than at an individual patient level. In summary:

• The DTC advertising for diagnostic tests is unregulated and needs oversight by appropriate regulatory agencies.

• Professional societies should develop guidelines for such advertising and for the appropriateness of such tests.

	Cardiovascular specialty hospitals and self-referral

Top Introduction Ensuring appropriate use of... Direct-to-consumer advertising... Cardiovascular specialty... Legal issues in self-referral Overview and summary References

 
The role and quality of specialty hospitals.   Cardiovascular specialty hospitals are a recent phenomenon. Although cardiovascular care has traditionally been a component of full-service general hospitals, in recent years a small number of free-standing cardiovascular specialty hospitals have been created. Virtually all of these hospitals are for-profit and are located in jurisdictions with minimal or absent governmental control over the creation of health care facilities.

The cardiovascular specialty hospital vision is a facility specifically tailored to provide optimal cardiovascular care. Ideally, a dedicated heart hospital can operate without any of the compromises that result from the design and resource competition issues of a full-service hospital. Such facilities typically offer complete inpatient and outpatient cardiovascular diagnostic and therapeutic services, but often do not provide many of the non-cardiovascular services that are traditionally included in a full-service hospital. Several incentives foster the creation and operation of heart hospitals:

1 The heart hospital architecture, equipment, and operational protocols can be optimized for cardiovascular care. Thus, it has the potential to provide the best working environment for cardiovascular health care providers and an optimal clinical care environment for patients.

2 Reimbursement rates for cardiovascular care under prospective payment systems are generally favorable. This gives the heart hospital reasonable reimbursement and a greater potential to be profitable, when compared to the full-service hospital, which provides many services for which prospective payment is less favorable.

3 Full-service hospitals, unlike heart hospitals, may divert revenue from cardiovascular care to support other service lines that are less well reimbursed. This does not happen in a heart hospital.

Conversely, there are potential concerns about the appropriateness and positioning of such institutions in the overall health care system. For example:

1 Can such institutions provide optimal care to all cardiovascular patients?

2 Do such hospitals undermine the strength and integrity of full-service hospitals?

3 Do physicians who invest in these for-profit hospitals have a conflict of interest when deciding where to admit a particular patient?

The U.S. General Accounting Office recently released a study of specialty hospitals in the U.S. that was commissioned by the U.S. Congress (24). It identified 15 currently operating heart hospitals with approximately a dozen more in various stages of planning and construction. Virtually all were for-profit institutions and virtually all had significant investment on the part of physicians who held privileges at that hospital.

With respect to economics and regional competition, the study found that, whereas the majority of heart hospitals were relatively small institutions, generally with 60 or fewer beds, they frequently had a major regional impact in that they tended to deliver a large fraction of the cardiovascular services in their service area. Thus, they had a potentially large impact on the cardiovascular service lines of the competitive full-service institutions in their region. The specialty hospitals tended to have a somewhat more favorable payer mix (smaller fraction of Medicaid-reimbursed patients) than the full-service hospitals. In addition, specialty hospitals tended to have a slightly lower case-severity index than full-service hospitals. All of these trends work to enhance such institutions' financial performance relative to full-service hospitals.

With respect to clinical quality, other published studies indicate that heart hospitals achieve outcomes comparable to those of full-service hospitals with a potentially reduced length of stay (25).

Ethical issues related to specialty hospitals.   Physician financial conflict of interest
Most heart hospitals are for-profit. Many are capitalized in part through physician investment. Thus, some physicians who have privileges at a heart hospital have a financial stake in the institution. It has been pointed out that, in most cases, physicians provide less than 50% of the start-up capital and, in general, individual physicians have small ownership shares (26). Thus, it can be argued that an individual physician's financial stake in an institution is modest, and a physician's income is not significantly influenced by the heart hospital's financial performance. However, the physician's capital is at risk, and should the hospital fail financially, he or she would stand to lose the capital investment. Thus, such a conflict might cause a physician to admit less complicated, better insured patients to the heart hospital while diverting the more complex, less well insured patients to the full-service hospital.

Impact on competing full-service hospitals
The full-service hospital is often a vital community resource, and the quality of health care within the community may be dependent upon its financial and clinical success. Heart hospitals can have a competitive advantage over full-service hospitals for several reasons, including more favorable payer mix and the ability to avoid caring for the more complicated cases under the rationale that such patients require services that might be offered only at full-service hospitals. Thus, there is the potential for heart hospitals to "skim the cream" of the cardiovascular service line. At this time, sufficient published studies are not available to evaluate this concern properly. In summary:

• Heart hospitals present an alternative to traditional full-service hospitals for the delivery of straightforward cardiovascular care.

• Heart hospitals have several characteristics that may be appealing to individual cardiologists and their patients.

• Heart hospitals may present a possible conflict of interest for involved physicians.

• Heart hospitals have the potential to affect a community's overall health care delivery system.

The ACC Board of Trustees has not taken a position for or against such hospitals, but has endorsed the following statement: "Given the wide range of opinions expressed by ACC members and the ACC Board of Trustees, the ACC recommends monitoring the data being collected during the 18-month congressionally mandated moratorium on specialty hospitals. There remains significant, unanswered questions about the financial impact on general, acute-care hospitals, patient severity of illness at referral, and quality of care in specialty hospitals. The primary concern of the ACC is delivery of high-quality cardiovascular care to all Americans; sufficient data do not now exist to judge whether specialty heart hospitals are a useful innovation or are detrimental to this mission. The ACC urges use of standardized databases such as NCDR and the Society for Thoracic Surgery in an objective analysis of the performance of specialty hospitals" (ACC Board of Trustees Minutes, December 18, 2003). Likewise, the AHA's primary mission is the reduction of disability and death from cardiovascular disease and stroke, and in the absence of adequate data, the AHA has not taken a position on heart hospitals. The AHA agrees that the data from the 18-month mandated moratorium must be studied carefully before conclusions can be reached.

	Legal issues in self-referral

Top Introduction Ensuring appropriate use of... Direct-to-consumer advertising... Cardiovascular specialty... Legal issues in self-referral Overview and summary References

 
The anti-kickback statute.   Fraud and abuse laws provide criminal penalties to those who knowingly and willfully offer, pay, solicit, or receive remuneration in exchange for referrals of patients or business reimbursed by a federal health care program (27,28). The law was aimed to prevent outright payments for referrals by clinical laboratories, home health agencies, durable medical equipment vendors, and other suppliers. These policies were enacted to:

1 prevent referrals based on financial benefit to the health care provider making the referral, rather than the greatest benefit for the beneficiary;

2 prohibit solicitation of such payments;

3 prevent overutilization of services; and

4 control governmental cost of providing health care coverage.

Violation of the statute is a felony punishable by fines of up to $25,000 and imprisonment for up to five years. Individuals found guilty might be excluded from participation in federal and state health care programs.

Congress also directed the Secretary of Health and Human Services to develop regulations that would specifically exclude certain arrangements from being considered anti-kickback violations. The safe-harbor exceptions recognize that there are legitimate reasons for a health care entity to pay a physician—as, for example, a hospital medical director—or for clinical laboratory oversight. Potentially illegal hospital-physician incentives have also been defined and can include the use of discounted office space or equipment in facilities usually located near the hospital. Such arrangements are considered inurements designed to influence physicians' utilization decisions. Fair-market lease agreements are advised to avoid such liabilities. The Office of the Inspector General accepts requests for formal advisory opinions although these may not be relied upon by third parties as legal precedent (28).

The Stark laws.   The Stark Law seeks to prohibit referrals by physicians of Medicare or Medicaid patients to facilities in which the physician has an ownership interest or from which the physician receives compensation (28,29). Compensation can be any form of remuneration, direct or indirect, between the physician or family member and the designated health service provider. These include clinical laboratory services, radiology diagnostic services, inpatient and outpatient hospital services, and durable medical equipment covered in the Medicare fee schedule. The Stark legislation is based on the presumption that physicians will overutilize such services if they profit from the referrals or the orders. "Stark" is distinct from the anti-kickback statute. First, Stark evaluates exclusively the financial incentives of the provider making the referral and not the intent of the parties. Second, Stark is a civil, rather than criminal, statute. Violators are not subject to criminal prosecution but may be excluded from federal health care programs and face civil monetary fines.

Much confusion has resulted from the passage of two Stark bills, from the complexity of the laws, and from the slow issuance of rational implementing regulations. Although the basic prohibition for a referral was clearly defined, Stark II provides exceptions to the general prohibition on referrals (29). The most common exception is the in-office ancillary services exception, when the service is performed within a group practice. In summary:

• The Stark law and the anti-kickback legislation are extremely complex and confusing. It has taken 10 years for the government to publish only a portion of the final regulations.

• Safe-harbors are difficult to interpret without legal counsel.

• Although these laws have prevented some of the most ethically egregious examples of kickbacks and fee splitting, they have not limited the significant growth in cardiovascular activities that are in part due to self-referral within the solo or group practice setting.

	Overview and summary

Top Introduction Ensuring appropriate use of... Direct-to-consumer advertising... Cardiovascular specialty... Legal issues in self-referral Overview and summary References

 
Both the ACCF and the AHA take seriously the responsibility of their members to optimize care for their patients. This can best be done by effective application of evidence-based medicine and practicing the highest standards of medical care. The issue of "self-referral" and its possible incentive for inappropriate utilization is an important consideration in medical practice. In this document, we have discussed the pertinent background of this issue and made positive recommendations to address this concern. Most self-referral is entirely appropriate. This "self-referral" is open and obvious to all parties. The management of self-referral also includes procedural laboratory oversight and accreditation and physician competence in a given procedure. Physician ownership of equipment outside of the physician's practice setting is a complex professional issue and should conform to AMA guidelines, which prominently include full disclosure and transparency.

The commercialization of screening tests and advertisements for these tests are largely unregulated. This field needs both regulatory oversight and guidance from professional organizations such as the ACCF, the AHA, and cardiovascular specialty societies.

Cardiovascular specialty hospitals have raised issues about potential conflicts of interest among physician investors and their possible impact on community hospitals. The ACCF and the AHA have not taken a specific position on this issue, but members of this Consensus Conference currently support the collection of more data about the quality of care and outcomes provided by such hospitals.

	Acknowledgments

 
The authors appreciate the review and commentary provided by J. Ward Kennedy, MD, MACC, FAHA, and Nathan R. Every, MD, MPH, FACC.

	References

Top Introduction Ensuring appropriate use of... Direct-to-consumer advertising... Cardiovascular specialty... Legal issues in self-referral Overview and summary References

 

1. The Medical Professionalism Project Medical professionalism in the new millennium: a physicians' charter Med J Aust 2002;177:263-265.[Medline]
2. Parmley WW. Changing guidelines on conflict of interest J Am Coll Cardiol 2001;37:1749-1750.[Free Full Text]
3. Parmley WW, Passamani ER, Lo B. 29th Bethesda conference: ethics in cardiovascular medicine (1997)Introduction. J Am Coll Cardiol 1998;31917–5..
4. The Council on Ethical and Judicial Affairs. American Medical Association. Code of Medical Ethics. Chicago, IL: 1997..
5. American College of Physicians Ethics Manual. 4th edition Ann Intern Med 1998;128:576-594.[Abstract/Free Full Text]
6. Pilote L, Miller DP, Califf RM, Rao JS, Weaver WD, Topol EJ. Determinants of the use of coronary angiography and revascularization after thrombolysis for acute myocardial infarction N Engl J Med 1996;335:1198-1205.[Abstract/Free Full Text]
7. Pilote L, Califf RM, Sapp S, et al. Regional variation across the United States in the management of acute myocardial infarctionGUSTO-1 Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries. N Engl J Med 1995;333:565-572.[Abstract/Free Full Text]
8. Every NR, Larson EB, Litwin PE, et al. The association between on-site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarctionMyocardial Infarction Triage and Intervention Project Investigators. N Engl J Med 1993;329:546-551.[Abstract/Free Full Text]
9. Wennberg DE, Kellett MA, Dickens JD, Malenka DJ, Keilson LM, Keller RB. The association between local diagnostic testing intensity and invasive cardiac procedures JAMA 1996;275:1161-1164.[Abstract]
10. Lucas FL, Wennberg DE, Malenka DJ. Variation in the use of echocardiography Eff Clin Pract 1999;2:71-75.[Medline]
11. Guadagnoli E, Landrum MB, Peterson EA, Gahart MT, Ryan TJ, McNeil BJ. Appropriateness of coronary angiography after myocardial infarction among Medicare beneficiariesManaged care versus fee for service. N Engl J Med 2000;343:1460-1466.[Abstract/Free Full Text]
12. Mark DB, Naylor CD, Hlatky MA, et al. Use of medical resources and quality of life after acute myocardial infarction in Canada and the United States N Engl J Med 1994;331:1130-1135.[Abstract/Free Full Text]
13. Ashton CM, Souchek J, Petersen NJ, et al. Hospital use and survival among Veterans Affairs beneficiaries N Engl J Med 2003;349:1637-1646.[Abstract/Free Full Text]
14. Fu Y, Chang WC, Mark D, et al. Canadian-American differences in the management of acute coronary syndromes in the GUSTO IIb trial: one-year follow-up of patients without ST-segment elevationGlobal Use of Strategies to Open Occluded Coronary Arteries (GUSTO) II Investigators. Circulation 2000;102:1375-1381.[Abstract/Free Full Text]
15. Jollis JG, DeLong ER, Peterson ED, et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician N Engl J Med 1996;335:1880-1887.[Abstract/Free Full Text]
16. American Medical Association. Code of Medical Ethics, Current Opinions With Annotations. Health Facility Ownership by a Physician 1998–1999. Chicago, IL: 1999..
17. Gibbons RJ, Smith S, Antman E. American College of Cardiology/American Heart Association clinical practice guidelines: part I: where do they come from? Circulation 2003;107:2979-2986.[Free Full Text]
18. Gibbons RJ, Smith Jr. SC, Antman E. American College of Cardiology/American Heart Association clinical practice guidelines: part II: evolutionary changes in a continuous quality improvement project Circulation 2003;107:3101-3107.[Free Full Text]
19. Mehta RH, Montoye CK, Gallogly M, et al. Improving quality of care for acute myocardial infarction: the Guidelines Applied in Practice (GAP) initiative JAMA 2002;287:1269-1276.[Abstract/Free Full Text]
20. Quinones MA, Douglas PS, Foster E, et al. ACC/AHA clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence J Am Coll Cardiol 2003;41:687-708.[Free Full Text]
21. Anderson HV, Shaw RE, Brindis RG, et al. A contemporary overview of percutaneous coronary interventions: the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR^TM) J Am Coll Cardiol 2002;39:1096-1103.[Abstract/Free Full Text]
22. Lim M. Fetal Photos and Body Scans in Parking Lots: The Implications of Bypassing Physicians in the Medical MarketplaceAvailable athttp://www.ama-assn.org/ama/pub/category/print/9154.html 2002Last update August 28, 2003.
23. The Council on Ethical and Judicial Affairs. American Medical Association. Code of Medical Ethics. Chicago, IL: 2002-2003, 91..
24. Geographic Location, Services Provided, and Financial Performance. GAO Highlights. GAO-040167. Washington, DC: October 2003..
25. Goolsby J. The evolution of the heart hospital of Austin: why we did it and what happened Am Heart J 2003;1:97-9103.
26. McLean T. The rise of the heart hospital and the fall of the House of Usher Am Heart Hosp J 2003;1:223-230.[Medline]
27. Torras HW. Health Care Fraud and Abuse: A Physicians Guide to Compliance2nd edition. American Medical Association; 2003.
28. The Corporate Compliance Task Force of the In-House Counsel Practice Group. Health Care Compliance Legal Issues Manual. 2nd edition. Washington, DC: American Health Lawyers Association, 2001..
29. Health Care Financing Administration (HCFA). Stark II Self Referral Regulation. American College of Physicians-American Society of Internal Medicine, 2002..

This article has been cited by other articles:

				P. S. Douglas President's Page: Reframing Debate in Patient Care Image J. Am. Coll. Cardiol., July 5, 2005; 46(1): 176 - 177. [Full Text] [PDF]

This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ritchie, J. L. Articles by Wann, L. S. Search for Related Content PubMed PubMed Citation Articles by Ritchie, J. L. Articles by Wann, L. S.