January 9th, 2012

What Are the Biggest Opportunities for Cost Savings in Cardiology?

Everyone is focusing on the escalating, and presumably unsustainable, increases in medical costs. When Don Berwick departed from the Centers for Medicare and Medicaid Services last month he estimated that 20-30% of medical spending in the US is waste—spending that provides no meaningful benefit to patients. The American Board of Internal Medicine (ABIM) Foundation has launched the Choose Wisely Initiative with 9 specialty societies—including the American College of Cardiology—and Consumer Reports to identify 5 tests or procedures in each field that should be carefully questioned to help reduce waste (see here for a recent news story).

Here is a chance for our community to contribute. Where is the waste? What could we eliminate without risking the wellbeing of our patients?  How many good ideas can we generate?

Comments are closed on this post, but please join the conversation at our news story on the ACC’s and the American Society of Nuclear Cardiology’s contributions to the Choosing Wisely initiative.

11 Responses to “What Are the Biggest Opportunities for Cost Savings in Cardiology?”

  1. Steven Greer, MD says:

    Johns Hopkins’ Dr. Smith discusses 5 ways to cut cancer therapy spending in wasteful areas


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  2. Robin Motz, M.D., Ph.D. says:

    And what test will a malpractice lawyer NOT sue you for NOT doing if the patient dies or suffers a heart attack or a stroke? No doctor ever got sued for doing a test, only for not doing one. And it can be difficult to convince a jury that a test was not needed if the patient suffers a bad result.

  3. William DeMedio, MD says:

    As has been seen at a few medical centers with some overzealous interventionalists, the greatest opportunity for cost saving in cardiology is the ability to cut back on unnecessary stenting. Maximal medical therapy has been shown to reduce CVD. We should reserve invasion for more severe cases and always optimize medication therapy to prevent disease both primarily and secondarily. Looking at the statistics, we have been quite successful at cutting back early cardiac death for over 25 years. In spite of the steady decline, CVD is still the number one killer of both women and men. We must continue to maximize our efforts using known methods to eradicate this disease. Great strides in smoking cessation, lifestyle modification, lipid lowering, anticoagulation, platelet inhibition, blood pressure control, and glycemic control have all played a part in dropping the risk of cardiovascular death. The hardware plays a secondary, yet vital role. Use it only when clearly needed and economic costs will come down. We have already made great strides in the true cost of the disease, I see many fewer people in their forties and younger dying of CVD now than 25 years ago.

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  4. Vaughn Payne, MD, FACC says:

    Unnecessary test ordering should be a focus. As a profession we need to start self-policing. It’s already begun by others. Why order a nuclear stress test when a plain treadmill will do? “Surveillance” stress tests…where’s the data? An echo for every new office patient, when a good H&P suffices? The list goes on.

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  5. 1) Eliminating CK and CK-MB from the cardiac enzyme panel (with considerable evidence to suggest it adds no incremental information to serial troponin measurements, as suggested in a compelling special report by Saenger and Jaffe (Circulation 2008)- we have calculated that at our institution alone, this would save nearly $1 million in hospital charges to patients
    2) Limiting troponin ordering to no more than 2-3 sets in all patients suspected of ACS (if a troponin is markedly positive or negative, there is no need to “trend” this value as the diagnosis is either made or excluded
    3) Concur with Dr. Payne that if we actually applied evidence-based guidelines in choosing what type of stress test was appropriate, there would be a significant reduction in the imaging component of stress tests (i.e. reducing the nuclear component when a plain old treadmill will do)

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  6. Van Crisco, MD says:

    Radial Access Same-Day Discharge PCI: http://issuu.com/scaipublications/docs/newsletter_2011-7 pg 22. the approach harnesses an access strategy associated with lower cost, fewer complications, and earlier ambulation with the awareness of the safety of same-day discharge in selected low risk post-PCI patients (http://www.theheart.org/article/1290247.do).

    Competing interests pertaining specifically to this post, comment, or both:
    I am co-founder of Radial Assist, LLC, (www.radialassist.com) a producer and distributor of devices designed to improve the operator and patient experience with upper extremity access endovascular procedures.

  7. There were 10,000,000 nuclear stress tests performed in the US over the last year. Considering that we now know that revascularization of obstruction adds to the net, no value, I fail to understand why we are spending almost 10 billion dollars in nuclear stress imaging to determine who will need a cath from which they will derive no benefit.

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  8. We all know that cardiologists order tests to maximize their income. They will use any excuse they can to justify the test to the insurance company. The idea that a cardiologist can be sued for not ordering a test has never been shown to be true. I practiced for decades and was sued a number of times, (never paid a penny), but was never sued for not doing a test. Never saw any of my partners or colleagues sued for not doing a test. The idea that one can be sued for not doing a test is just an excuse used by the medical community to get away with massive overutilization of unnecessary testing and procedures in order to increase incomes.

  9. Robin Motz, M.D., Ph.D. says:

    I personally was sued (and won the case) because a female patient who had been successfully treated for Hodgkin’s disease refused for seven years, as documented in my chart and in her gynecologist’s chart, to have a colonoscopy or even to do a stool for blood. She developed and died from colon cancer. Her husband sued me and the gynecologist for not having had the colonoscopy done. The case was finally dismissed with prejudice, but it just means I have to answer “yes” to the question “were you ever sued for malpractice”. I would much rather, or course, not have been sued, and have never again been sued for failure to do a test. The gynecologist now fires from his practice any patient who refuses a colonoscopy.

    • Cardiologist’s don’t do colonoscopies. I have seen a cardiologist sued for doing an unnecessary catheterization which caused a patient to have a massive stroke. Clearly the problem is not one of failing to do necessary testing. The problem is knowingly doing tests that are not necessary just to make money and using the risk of a lawsuit as an excuse. Non invasive testing is rarely dangerous. In my state if a procedure is not indicated and causes a serious complication that is a statuatory definition of malpractice.

  10. Beat J. Meyer, M.D. says:

    If I am convinced that a test is currently not indicated I first document it in the chart. If the patient is still keen on having the test, I explain to him that he is about to ask for an unnecessary test. Then, I describe the risks and the costs and try to reassure him that the test can be done anytime in the future, if necessary. If the patient is still anxious and thinks mistakenly that the test is helpful in preventing future events, I become frank with him and say: oh, that reminds me of one important reason to do the test: “you can certainly help me with the amortisation of my toys”. Using this paradoxical intervention, there is 1:20 patients who will continue to insist on having the test. Depending on the patient I might turn him down or I do the test for his peace of mind and write in my chart: test done for the patient’s ATARAXIA.

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