December 2nd, 2013
Left Ventriculography: Procedural Variation Writ Large
The Dartmouth Atlas Project has documented that the use of many procedures varies widely by region and by institution, raising the question of whether much of the care in high-use areas may be unnecessary. At Palo Alto’s Veterans Affairs Health Care System, where I practice, our cardiology fellows noticed that the use of left ventriculography varied markedly depending on whether coronary angiography was performed at the VA itself (lowest use), at the university hospital by academic staff, or by private physicians (greatest use).
So we conducted a study, now published in Circulation: Cardiovascular Quality and Outcomes, of the use of left ventriculography during coronary angiography across the VA Health Care System nationwide from 2000 to 2009. We found an overall rate of 58% but with dramatic variation: as high as 95% in some facilities and lower than 1% in others. Differences in reimbursement do not explain the variation, given that VA providers are salaried and that most private payers don’t reimburse much for left ventriculography. Other factors must, therefore, be at work.
We have heard, anecdotally, that one VA facility reduced its use of left ventriculography by more than 80% within 8 years despite turnover in just a few interventional cardiologists. However, no published performance measures, guidelines, or appropriateness criteria exist for left ventriculography, so we can’t systematically assess where care is “best.” We did manage to document that even in cases where an echocardiogram was performed in the prior 30 days with no intervening admission for a cardiac cause that might prompt a change in LV ejection fraction, left ventriculography was still performed in 50% of patients. Although that seems like inappropriate use of the procedure, if the clinician does not trust the echocardiogram, he or she may feel compelled to do a left ventriculogram.
So I ask you: Does the variation in use of left ventriculography represent reasonable differences in opinion among clinicians? Or do some of us have unrealistic expectations about the benefits and harms of the procedure?