COMMENTARY

Wide Variations in CV Care: A Wake-up Call for Cardiologists

John M. Mandrola, MD

Disclosures

July 10, 2013

If you are a cardiologist in the US, today's issue of the Journal of the American Medical Association will make for tough reading. Two articles shine a bright light on blemishes in practice patterns. As a cardiologist, I find it to be awful news. I urge you not to look away.

Variation in Care Among Medicare Patients

In the first study, Dr Dan Matlock and colleagues at the University of Colorado looked at nearly six million Medicare patients from 2003 to 2007. They discovered rates of major cardiovascular procedures differ between patients enrolled in Medicare Advantage (capitated and managed) plans and traditional fee-for-service (FFS) plans. Even though researchers carefully controlled for age, race, sex, and income, procedure rates for angiography and PCI were significantly lower for patients enrolled in Medicare Advantage plans compared with those in FFS plans. Less elective procedures like urgent angiography or CABG surgery did not differ. Perhaps worse, nonurgent procedure rates (for both groups) varied widely across geographic regions, and these variations did not appear related to disease-specific causes.

Variation in Care Based on Location

In the second study, Dr Dennis Ko and colleagues from Toronto, ON, added to their previous work on cardiac procedural differences between two adjoining geographic regions, New York State and Ontario. Previous work from this group has shown much higher cardiac procedure rates in New York. The current study reveals that the increased use of cardiac catheterization in New York relates to selection of more patients at lower risk of obstructive coronary artery disease. In New York, the observed rate of CAD during catheterization was 30% vs 45% in Ontario. Cardiologists in New York discovered important findings like left main stenosis and three-vessel disease significantly less often than their peers in Canada. The proportion of low-risk patients who underwent catheterization was more than double in New York, 15% vs 6.9%. Despite these different practice patterns, mortality for patients who had catheterization was slightly higher in New York than Ontario (0.65% vs 0.38%).

Why Are These Studies So Troubling?

Let's agree that some variation in practice patterns is reasonable. Obviously medicine can't be completely codified. Cardiac procedures like angiography and PCI, however, are grounded in a strong evidence base. Science has led to well agreed-upon guidelines and exhaustive appropriate-use criteria. Cardiologists have become known for the randomized controlled trial. And we study more than just drugs and devices; we study entire strategies (and approaches) to problems like stable coronary artery disease. So I ask, if all these data exist, good data, how can payment models or geographic locations affect rates of procedures, or worse, the yield of procedures?

This should not be. It's an ugly blemish. And we shouldn't look away. We should look right at it, study it, accept it, and figure out what to do about it. Take the ICD example: Although the Dr Sana Al-Khatib 2011 paper published in JAMA had its flaws, the fact remained that many ICDs were being implanted outside of established evidence. That was a wake-up call for the electrophysiology community. I believe it was an inflection point for improved decision quality in ICD care. We aren't there yet, more work remains, but accepting that blemish started the ICD community on a path toward more rational use of ICDs.

Time Out

Could this be an inflection point for general cardiology practice? I hope so. How much more data are needed to convince smart doctors (and patients) that less is more? I saw three patients last week who had coronary stents placed for asymptomatic coronary disease. In each case, the presence of a metal cage in a coronary artery complicated the management of symptomatic arrhythmia. These patients were asymptomatic when they had the stent and they remained that way now. What was gained?

We know (and have known) that atherosclerosis is a systemic disease, and its treatment requires more than just opening a partial obstruction. The antiquated and magical notion of "fixing" people with the squishing, propping open, or even medicating of blood vessel disease needs to be resected from our minds. Yes, improving the physics of blood flow has a role, but we have evidence telling us when it works and when it doesn't. A patient's geographic location or payment plan should play no role in these decisions. What works for systemic diseases are systemic solutions—for instance, in the case of coronary disease, something like lowering inflammation with good sleep, good food, good movement, and good attitudes.

But there is something else that should play a role here: the patient's preference and decision quality. This is the next frontier in cardiology, and we, as big, strong heart doctors, need to stop being so frightened of it.

Selecting the Right Path

Modern cardiology, this generation if you will, was brought up on emergency interventions—CCUs first, then thrombolysis, and currently, acute PCI care for STEMI. But now, the overwhelming majority of decisions in cardiology are preference sensitive. The preference-sensitive decision is one where multiple paths exist, each with different trade-offs and one not more right than the other. Clinical examples include the approach to the non–high-risk stress test, the asymptomatic 70% circumflex lesion, the entire treatment protocol of atrial fibrillation, and the choice to implant an ICD.

We can also agree that no patient with asymptomatic CAD should think that their stent prevents MI; no patient should have an ICD implanted because they think they'd die without it; and no patient should agree to swallow a statin solely because it moves a biomarker one way or the other. That's wrong thinking.

It is well past time to move our thinking forward. Wide practice variations in procedure rates based on geography and payment plans should sound an alarm. I am proud to be a cardiologist—for a lot of reasons. One is that we have always been leaders in practicing evidence-based medicine.

Now it's time for us to lead again. We must show the medical community that decision quality is not only possible, but it will lead to true quality care. For if care is aligned with a person's goals and we have removed fear and ignorance from the process, then both patient and doctor will have arrived at the best place in the practice of medicine.

It's a place that makes me sleep well at night.

JMM

See also:

Studies Highlight Variations in CV Care by Region and by Payment Program

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