July 12th, 2011
Pass (Up) the Guidelines, Please
Richard A. Lange, MD, MBA and L. David Hillis, MD
The Occluded Artery Trial (OAT) demonstrated no benefit of routine PCI in persistently occluded infarct-related arteries identified more than 24 hours after MI. These results were incorporated into the revised guidelines for STEMI, NSTEMI, and PCI (published in 2007 and 2008) as a class III recommendation (i.e., not indicated and inappropriate). The senior investigator for OAT — and coauthor of the revised STEMI guidelines — now reports that the results of OAT have not been incorporated into practice: many patients still undergo late reperfusion (>24 hrs) with PCI of the occluded infarct-related artery despite being asymptomatic and stable.
Why haven’t the guidelines been implemented?
Are many physicians unfamiliar with the guidelines? Possibly. Many busy practitioners find the exhaustive guidelines exhausting to read: excessively long and difficult to navigate.
More likely, physician and patient barriers play a large role in the inappropriate use of angiography and PCI, as we highlighted in a previous editorial. How so?
- In an era in which invasive cardiac procedures are manifestations of high-technology, resource-intensive medical care, many patients expect and insist on aggressive management. The term “conservative management” may project the impression (to physicians and patients alike) of obsolescence, inadequacy, and inferiority rather than of thoughtful reflection and the application of scientifically based, ischemia-guided therapy.
- Physicians are skeptical about the applicability of the results of trials (and guidelines) to their patients. We refer to these as the “DAM” studies (Doesn’t Apply to Me).
- Studies that substantiate preconceived notions are likely to be embraced and their recommendations followed, whereas those that do not are often ignored.
- The abundance of facilities for prompt angiography and revascularization, physicians trained to perform these procedures, and monetary remuneration to the facilities and physicians encourages the use of angiography and revascularization without a clear indication.
In the event of an adverse outcome, the patient and his or her family may be more understanding and forgiving if an aggressive approach was pursued (i.e., if “everything possible was done”), even if such an approach contributes, directly or indirectly, to the adverse outcome.
Do we need more guidelines? Probably not, since we don’t effectively implement the ones we have.
What are your thoughts? How can we more effectively integrate guidelines into clinical practice?
3 Responses to “Pass (Up) the Guidelines, Please”
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Physicians, like people, will choose the path of least resistance. Do a cath, find a blockage, fix a blockage – the patient can understand this, and the physician gets paid well for it. It is far more difficult – but extremely important – for the physician to explain to a patient and family that fixing a blockage will be of no benefit or possibly be more harmful than leaving it alone. And it is far more difficult for the physician to walk away from the additional revenue that a PCI brings, even if it is not appropriate based on guidelines.
Short of peer-reviewed audits of appropriateness tied to financial incentives/disincentives for guideline adherence, or a return to capitation (now known as bundling) payments, interventional cardiologists – sadly – will not change their ways.
Changing behavior is difficult even when there is a clear cut difference in outcome; The OAT trial, as a negative trial narrowly defined in a cohort of STEMI and NSTEMI patients, demonstrated no benefit but also no harm but a trend toward increased reinfarction. Definitely a gray area.
The CATH PCI registry, while it does include fields for STEMI and NSTEMI, does not provide sufficient detail on infarct related artery, clinical presentation or non invasive testing to understant what role these clinical variables played in the clinical decision process. As most patients in the CATHPCI registry presented with NSTEMI, the clinical exigency may well tip the scale in favor of revascularization in the balance of risk versus benefit.
As others have identified, the interplay of patient and referring physician expectations as well as financial incentives have unknown and difficult to dissect influence on the decision to intervene on an occluded vessel in an individual patient.
How do we change behavior….We measure it with peer review such as the new ACE program (SCAI/ACC), we reward it by altering financial incentives and we recognize it in social currency (AHA/ACC guidelines compliance etc).
Competing interests pertaining specifically to this post, comment, or both:
none
Remember that th eoar trial was published years ago and the techniques are somewhat bettr. Careful reading of the study showes less ventricular dilation and fewer patients with class three angina in short trem followup. Longer term followup will be of interest to me to see if an open artery gives protection over 10 to 20 years. The switch to drug eluting stents, angiomax and export thrombectomy will likely impact todays patient. There wa no statistc harm to these patients althought he authors claim there was a “signal” of more MI’s. What are we to do? The patient comes in 24 hours after an anterior MI and still has some recurring discomfort. Cath shows an ef of 45 and a totally occluded lad. Is this the time to do a stress test? Should a viability study be done if the anterior wall still moves? Remember that a fresh occusions is miles easier to open than a 4 month old occlusion. Are we subjecting ourselves to guideline tyranny? Personnaly, I would want my LAD opened quick!!!Never mind about bringing me back later if my stress test is postive or my chest hurts of I develop chf. I am all for evidence based medicine but a NEJM tagline does not mean it is the LAST WORD.