Seth Bilazarian, MD


May 29, 2014

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Hi. Seth Bilazarian on on Medscape, for my Private Practice blog. I want to comment on a paper called "Measuring Low-Value Care in Medicare" that was published in JAMA Internal Medicine on May 12.[1]

I want to give some comments. As a community-based clinical cardiologist, I work in a cardiac cath lab. Those are essentially my disclosures.

I want to comment about what I think is a pendulum swinging from physicians being an integral part of healthcare delivery, and problem-solving in that delivery, to being seen as a major impediment and cost-driver, which I think is a significant detriment. This paper concerns me as a clinical cardiologist in several ways. I am a retail deliverer of cardiology. I don't look at healthcare policy; that is not my profession. I am a practitioner. The discussion in this paper was at a higher level than where I practice, but I think it has important implications and I want to share with the Medscape community and get other physicians to weigh in.

I see this in context with many other initiatives which I will mention. Of course there is (1) appropriate-use criteria, largely directed at physicians; (2) Choosing Wisely®, largely directed at patients, with the idea that physicians discuss these issues with patients; (3) comparative effectiveness, discussing healthcare policy, and then (4) low-value care, which is the topic of this paper.

My only other disclosure -- which is not a bias but may limit my scope of comment -- is that I'm a practitioner in Eastern Massachusetts, which is heavily involved with managed care, and I may have a different perspective than other physicians nationally.

I certainly see the wisdom of efforts to reign in and control healthcare costs; 18% of gross domestic product is going to healthcare. That is an important issue for me as a physician, but also as a taxpayer, as a patient, and as a family member of patients. I want to give excellent care. I want patients and my family to receive excellent care. These are important issues that we all face, but I have some concerns about the way this paper had been presented. This is just a discussion of how it's going for us as clinicians.

I have 5 concerns. First, the term "low value" -- what does low value mean? Value, obviously, is in the eye of the beholder. But of course I don't like the reference of low value. I don't want to give low-value care. I want to give excellent value. I want to give good value. The problem with this paper is that they define essentially all elective angioplasty as low value. They do a sensitivity analysis whereby any patient who had an angioplasty, who had a prior diagnosis of coronary disease more than 6 months ago but who did not go to the emergency room before their PCI, had a low-value PCI. As a practitioner, you can quickly think of a patient you saw with an accelerated pattern of angina, and you avoided emergency department use. You admitted the patient and did a PCI of a proximal LAD. That's certainly not low-value care. I think any clinician knows that that's not low-value care, but this is called low-value care [in this paper], and of course, words have power.

When we see the implication of words having power in what the appropriate-use criteria have done -- changing the "inappropriate" category to "rarely appropriate" because of the important implications of the words -- the term "low-value care" is certainly a concern for me.

The second concern I have is that their definition of elective PCI in patients who've had prior diagnosis of ischemic heart disease is comically not sensible. Using the emergency room as a differentiator doesn't make sense to me because we are really avidly and aggressively trying to avoid emergency department use to reduce costs. We are trying to limit length of stay. We're trying to get patients in and out of the hospital more quickly, using same-day discharge. The emergency department differentiator makes no sense. It's actually counterintuitive.

Another issue that makes no sense here is for those people who believe that the COURAGE trial[2] is the way we should practice -- using optimal medical therapy and delaying PCI only for those patients who can't tolerate optimal medical therapy. In that very trial, almost a third (less than half a percent less than 33%) of the patients randomized to optimal medical therapy alone crossed over to PCI. So, those patients in the COURAGE trial would have received low-value care based on the definition in this paper.

A third concern I have is payment implications. When the appropriate-use criteria came out, we were told that this was not going to be used for payment. But just this week, New York Medicaid announced that they will retroactively not pay for inappropriate PCIs using the AUC calculators. We know these kinds of issues are important, so we can't be passive and say, "Well, this is a healthcare policy exercise." These kinds of issues are going to affect payment, and of course it's going to have implications for patients' delivery of care.

A fourth important issue is that these will have policy implications. If the goal is to drive down costs and save money for our society and to give good care at lower costs, then pursuing the wrong diagnosis (to use the disease metaphor) is going to lead to the wrong treatment and delay treatment for the right problems. I don't know what all the right problems are in regard to the high cost of care, but I know it's not that all elective PCIs (estimated to be over $2 billion in this study) are the cause of the high cost of medicine. I am certain of it.

The fifth concern I have is patient messaging. What does it say when patients know or learn that they're been submitted to "low-value care"? This was touted on many Websites when this paper was released. It was also shown in several articles in the lay press that might not have delved into it the way I did. But it's not long until people will consider all of these things as low-value care. There were 5 cardiovascular tests and procedures [in this paper]. I'm focusing on one: elective PCI.

And, of course, the other issue is, whose values are being considered when it's considered low-value care? When we talk about low-value care, we're really talking about a comparative of effectiveness, not comparative effectiveness leading to some kind of good outcome. We're currently instructed, or highly recommended, to use shared decision-making to include patients' values. Patients' values may include anxiety about a diagnosis, so undergoing a procedure may be part of a patient's value system and is a really very high value. To label it as "low value" creates a real problem for our discussions with patients.

The last comment that I'll make is about trying to sort out where the costs can be reduced. Where we can do a better job with saving patients' resources is really like making sausage, and we really need to do a good job with it. But publicizing it in this way, where a procedure is deemed low value or high value is really problematic as we go forward, until we get more confidence in being able to say to patients, "This really is a low-value procedure." I think that this group, from a very reputable medical school and in a very reputable journal (JAMA Internal Medicine), has done us a disservice by putting us out there without really using solid criteria for defining what is low value.

If any of you agree with me, I'd love to hear your comments on our Website here. Until next time, I'm Seth Bilazarian. Thanks a lot.


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