November 12th, 2010
Time Out!
Brahmajee Kartik Nallamothu, MD, MPH
This week, JAMA published a commentary that Harlan Krumholz and I wrote about the growing use of ad hoc PCI and its implications for decision making about coronary revascularization. To cut to the chase, we believe that ad hoc PCI — the performance of a diagnostic cath and PCI in the same setting — makes it challenging to incorporate findings from landmark studies like the COURAGE and SYNTAX trials into routine clinical practice. As a solution, we suggest that in stable patients, interventionalists consider “pausing” for a few days between the diagnostic cath and the PCI. Bill Boden — the lead investigator of the COURAGE trial — is currently exploring the feasibility of implementing such a waiting period in a collaborative effort with payers in upstate New York. Existing payment systems often discourage two separate settings for diagnostic cath and PCI because doing them at the same time is deemed more efficient. However, we are concerned that we may be performing PCI on patients who would have done just as well with optimal medical therapy or whose coronary anatomy would have been better suited to coronary bypass surgery.
But I think the biggest hurdle that Bill and others may face in such endeavors is the public’s distorted view of PCI. A recent study shows that patients continue to have outsized expectations about the benefits of PCI that are simply unjustified by the available evidence. As an interventionalist, I’ve found that patients (and referring providers) frequently arrive at the cath lab with the belief that if a blockage is found, it should be “fixed” right away. This places undue pressure on everyone to make immediate decisions that may not be in the best interest of the patient.
So, do others feel this type of pressure as well? Is a “pause” something that physicians, insurers, and patients would agree to implement in your practice?
5 Responses to “Time Out!”
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Even a greater degree of pressure may come from insurers than comes from patients’ expectations. True, patients have the expectation of same day PCI, and to disrespect this desire may jeopardize relationships with patients and referring physicians in the world of private practice.
Perhaps even more importantly however, constant scrutiny from insurers would quickly identify a given interventionalist as an “outlier” if he/she performed sequential diagnostic and therapeutic procedures. On the eve of the creation of hospital administered Accountable Care Organizations, making such a unilateral change may be economic suicide.
While there may be increased safety and accuracy in the old practice of sequential diagnostic cath and intervention, elimination of “ad ho” PCI in today’s economic climate will require a system wide approach.
Competing interests pertaining specifically to this post, comment, or both:
GE Health Care Consultant
I applaud your recommending a wait period to see if medicine will work as well as PCI or, if intervention is needed, if bypass would be the better procedure for the individual patient. I think this is one of many examples where it could be very helpful for doctors to write blog posts or articles for the public explaining your recommendation, in addition to writing for other physicians in medical journals. Doctors and journalists both need to inform the public. This would help ease the concern expressed by Alexander Stratlenko MD in his comment because if the public understands and wants the delay period, then many doctors would probably practice this way and insurers would come to view it as the norm.
Thanks to both of you for your comments. I agree that the current reimbursement system is actually stacked against “pausing”, which is troubling. Like Alexander noted, this means system wide efforts are needed to make this really work. But like Mary suggests, I think the bigger challenge may be the public. It is therefore our role to continue to educate patients about situations when it is best to proceed versus when we should take our time.
What about looking across the ocean?
Guidelines on myocardial revascularization from The European Society of Cardiology 2010 (doi:10.1093/eurheartj/ehq277)
It reads:
Ad hoc PCI is convenient for the patient, associated with fewer access site complications, and often cost-effective. However, in a review of more than 38 000 patients undergoing ad hoc PCI, 30% of patients were in categories that were regarded as potential candidates for CABG. Ad hoc PCI is therefore reasonable for many patients, but not desirable for all, and should not automatically be applied as a default approach. Institutional protocols designed by the Heart Team should be used to define specific anatomical criteria and clinical subsets that can or cannot be treated ad hoc.
Perhaps this debate about ad hoc PCI (aka Cath Possible or Drive-By-PCI) is really a great argument for cardiac CTA! Understand the anatomy, talk to the patient, collect any functional/physiological data beforehand that may be relevant to whether to PCI or (more likely) not. All this occurs before one is faced with the snap decision while “in the groin” without an understanding of the data and the Patient’s preferences. Isn’t this true informed consent?