February 2nd, 2012

The Biggest Opportunities for Cost Savings in Cardiology: Take II

In response to my recent post, we received some nice suggestions about where to eliminate waste in cardiovascular care. There were also some interesting concerns. We welcome more. Here are the suggestions that stood out:

  • Seek to optimize medical therapy over stenting for some patients.
  • More judicious use of imaging with stress tests.
  • Avoid using biomarkers for ACS in circumstances where they are highly unlikely to modify your approach.

Let’s work with these suggestions. Since clinical decisions are made case by case — and each situation has its own nuance — how do we move the needle to decrease testing and treatment that does not provide any benefit? Can we become more specific about where there are opportunities? How would it work best? What would our community suggest?

And surely you have additional suggestions for areas where we can use fewer resources without compromising the care of patients (or even to improve it). Consider this a suggestion box for cardiology. Please share!

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.

7 Responses to “The Biggest Opportunities for Cost Savings in Cardiology: Take II”

  1. As suggested by Saenger and Jaffe in a 2008 Circulation article (http://circ.ahajournals.org/content/118/21/2200.full), we should recommend that all patients undergoing evaluation for suspected acute coronary syndrome be evaluated with troponin assay alone, as the total CK and CK-MB add no additional information with respect to making the diagnosis of ACS. Continuing to order CK and CK-MB simply adds cost to the patient bill without any diagnostic benefit and would save millions of dollars.

    At our hospital alone, elimination of CK/CK-MB (except for other clinical situations in which CK might be helpful, such as rhabdomyolosis, muscle disorders, etc.) would reduce hospital charges by nearly $1 million annually. We have educated our physicians with regard to the use of troponin alone, moved to a protocol which eliminates the CK and CK-MB in the diagnostic profile of patients with ACS (as the Mayo Clinic has already done), and implemented electronic changes to discourage the overuse of troponin (i.e. ordering more than 3 sets within a 24 hour period in a patient with normal values).

    • Mark Cooper, BBA, Prospective MD 2013 says:

      How does your hospital determine the acuity of the event and the indication for PCI? Could a diabetic neuropathy obscure a patient’s pain symptoms and lead to a late report of MI, one in which Troponins are still elevated? Generally I’d hope the patient’s history of symptoms can guide us, and that’s what I saw practiced on our Stroke Service as we considered tPA use. As a student, I’ve wondered about the utility of CK-MB, and during rounds presented findings to suggest we discontinue its use on our particular patient who had abused crack cocaine (CK-MB may be elevated by cocaine use, without ischemic myocardial damage and has little specificity). Thanks for your thoughts.

  2. Mario Maiese, DO says:

    Stop doing studies and procedures without proven benefit i.e. CAC scoring, CAT angio etc. Recent data shows that optimal medical therapy is just as good and safer that CEA or carotid stenting. Therefore until a study is done showing benefit, CEA should not be paid for and if that is the case, we could eliminate a lot of carotid doppler studies. The CMS was going to address both of these issues but “caved” under the relentless lobbying.
    It is all very sad. It’s all about the money.

    Competing interests pertaining specifically to this post, comment, or both:

  3. Steven Greer, MD says:

    Some people in oncology made similar recommendations in NEJM, see our video discussion


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  4. Mario Maiese, DO says:

    Performing Fractional Flow reserves in most coronary visualization procedures to determine more accurately the need for PCI would decrease costs and improve outcomes.

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  5. There are obviously many ways to cut costs in cardiology. But the only way to get cardiologists to do it is to actually measure the costs incurred by each doctor. Then increase the fee schedule for low cost doctors and reduce it for high cost doctors. Otherwise cardiologists will continue to overutilize tests and procedures in order to maximize their incomes. Of course, severity of illness adjusted outcomes must also be measured simultaneously to insure that actually needed tests and procedures are not be withheld. Doctors with better outcomes should also have their fee schedules increased. Doctors with worse outcomes should have their fee schedules reduced.

    The only way to increase quality and lower costs is to measure both and pay doctors who achieve both more money. This is how market capitalism works. You get what you pay for. If we want more quality and lower costs then both have to be measured. If something is not measured it cannot be assessed. This is just simple mathematical logic. Nothing more, nothing less.

  6. The best road to cost savings in cardiology as well as in many medical specialties would be to reimburse for cognitive services sufficiently that physicians could make a reasonable living without the need for expensive procedures. Reimburse stress imaging and echo cardiography at cost.

    MI prevention is not accomplished in the stress lab or echo lab but in the office discussing lifestyle changes with patients. This is where reimbursement should be high enough to make physicians want to spend their time with patients, actually preventing illness.

    Competing interests pertaining specifically to this post, comment, or both: