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Ralph Brindis, MD, MPH,
FACC is the Immediate Past President of the American College
of Cardiology,
senior
advisor for cardiovascular disease for Northern California
Kaiser, clinical professor of medicine at the University of
California, San Francisco, and an affiliated faculty member
of the UCSF Philip R. Lee Institute for Health Policy Studies.
Dr. Brindis is a practicing invasive cardiologist with an
active practice of consultative cardiology. His major interest
in process measures
and outcomes assessment in cardiovascular disease has led
him to assist in the creation and implementation of various
cardiovascular
guidelines for Northern California Kaiser.
Dr. Brindis was Chief Medical
Officer and Chair of the National Cardiovascular Data Registry
(NCDR®) Management Board and also chaired the ACC Appropriateness
Oversight Task Force developing Appropriate Use Criteria
for non-invasive testing and coronary revascularization procedures.
Dr. Brindis
has over 100
publications in national peer-reviewed cardiovascular journals. |
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Ralph Brindis,
MD, MPH, FACC |
Q: The data used by the study
on PCI Appropriateness1 that was published this week in JAMA
was drawn entirely from
the National
Cardiovascular
Data Registry (NCDR) – an effort that was started in 1997 by
the American College of Cardiology. You’ve been at the helm
of this effort since it began. How representative of the total
U.S. interventional cardiology community is the Registry?
Dr. Brindis: I think our penetration now is pretty damn high. We
now have over 1,400 hospitals submitting data and this study really
represents the last 500,000 angioplasties that have been reported
to the NCDR. It's fairly recent data, so I'm pretty excited about
its importance.
This Registry is supported in terms of the expertise
by both the American College of Cardiology and the Society for Cardiovascular
Angiography and Interventions (SCAI) and I view that this is a
fantastic example of how two professional societies appreciate
the need for
measurement, appreciate the need for quality, have shown professionalism
and the concept of self-regulation, in the desire to improve patient
care and patient outcomes and, in this case, with appropriateness,
to be better stewards of our healthcare dollars, so that we make
sure we do the right procedure for the right patient at the right
time.
The amount of pride I have over this particular effort, which costs
the ACC a substantial amount of money, is great. It's such a huge
contribution to the healthcare of the United States of America,
particularly as we go forward in healthcare reform and come up
with new payment
models where we are trying to pay for quality and not for quantity;
where we come up with disease-bundling and payment for bundling
and episodes of care. I don't have to be a rocket scientist here,
but
I will predict that the NCDR and the CATH-PCI Registry will have
a huge role in the new reimbursement models in terms of differential
payment for quality and even figuring out reimbursement for quality
and it will incorporate our appropriateness data in doing such.
Q: What is your perspective on the
JAMA PCI Appropriateness study?
Dr. Brindis: I'm actually very excited about this study. Interventional
cardiologists have been under attack for the last couple of years,
ever since the COURAGE trial, about doing inappropriate angioplasties.
I think we've been targets because 43% of MEDICARE expenses are
cardiovascular in nature. So people are trying to figure out how
you decrease costs
-- and have been pointing, looking directly with their rifle-sites
aimed at the world of cardiology, and in particular the interventional
cardiologist.
"Dr.
Oz on the Oz Show, just this past November,
actually told his viewers that
50% of all angioplasty is unjustified and inappropriate,
doing an incredible disservice." |
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We've had particularly negative press that
you're well familiar with. About a year or so
ago, Dr. Elliot Fisher went on the Katie Couric
six o'clock news, and stated that from his perspective
well over 30-40% of all angioplasty is inappropriate,
or not necessary. And then Dr. Oz on the Oz Show,
just this past November, actually told his viewers
that 50% of all angioplasty is unjustified and
inappropriate, doing an incredible disservice.
And then, of course, increasingly we are hearing
reports in different states, related to individual
physicians that have been allegedly performing
inappropriate angioplasty. I guess the famous
one right now is the Maryland case with Dr. Midei
with his alleged inappropriate angioplasty, but
there are other examples from Louisiana and now
other states are looking into it such as Pennsylvania
and Iowa. So again, interventional cardiologists
are in the cross hairs in terms of excess angioplasty
and inappropriate angioplasty. |
But let me step back. We view that,
as a professional society, we have a privilege of self-regulation.
And if we don't do self-regulation
in a responsible
manner, other
people are going to do it to us, and they will use methodologies
that a clinician or expert would not agree with. I would say that
the American College of Cardiology and the vast majority of the
professionals in the ACC appreciate this responsibility of self-regulation.
So
the American College of Cardiology developed its Appropriate Use
Criteria document, which was published in JACC in January 2009,
where for the majority of clinical scenarios that we perform coronary
revascularization,
we have developed criteria for “appropriate”, “inappropriate” or “uncertain” to
perform revascularization.
Then the National Cardiovascular Data Registry
(NCDR) incorporated new data elements, so that we can accurately
assess as to whether
clinicians are performing PCI for appropriate means. The way that
we do this -- it's related to five domains: how patients present,
that is whether they have just stable angina up to a STEMI; what
their degree of symptoms is, whether they're asymptomatic, back
up to Class IV angina; the amount of ischemia on noninvasive testing,
whether there's none or a lot; the amount of medication they’re
on, whether none or the kitchen sink; and then, of course, the
burden of disease by coronary arteriography, you know, single,
double, triple,
left main disease. And looking at those domains, related to our
clinical patients and also whether they've had previous bypass
surgery or
angioplasty or whether they're diabetic or LV function, we have
a gradient as to whether it's appropriate, inappropriate or uncertain
to perform angioplasty.
What's so fascinating about this study is the
good news that in general we're pretty appropriate.
An important point is that almost 71% of all
angioplasty is performed for either STEMI, NSTEMI
or for acute coronary syndrome or unstable angina.
And that the nation performs PCI for stable angina
about 29% of the time So this is actually in
contradistinction from the first page of the
COURAGE trial in the New England Journal of Medicine
which implied that maybe 70% or more of angioplasty
is for stable angina in the United States...and
that simply is not true! Well over 70% of all
angioplasty in the United States is for acute
syndromes. And when Paul Chan looked at that,
based on our clinical practice guidelines and
appropriate use criteria, 99% of the time those
patients are getting PCI for appropriate reasons.
So that's the good news. |
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"...the
COURAGE trial ...implied that maybe
70% or more of angioplasty is for stable angina
in the United States...and that simply is not
true! Well over 70% of all angioplasty in the
United States is for acute syndromes." |
And then when you look at the overall data of the study, the amount
of inappropriate angioplasty is actually in the single digits.
It's not high compared to what Dr. Oz or Dr. Elliot Fisher said.
Now clearly we have opportunities for improvement. I think one
of the important messages from this study, in addition to validating
in general what most interventional cardiologists are doing, is
that
when you look at the stable angina population, clearly we have
opportunities for improvement in terms of inappropriate or uncertain
patients in
that group getting angioplasty.
To me the most telling piece of this study
is the graph of the marked variability in our hospitals in terms
of the degree of inappropriateness
of PCI in this stable angina population which range from as low
as
0% to as high as 50-60%. That tells you no matter if an interventionalist
says, "Oh, the appropriateness criteria are garbage. You're
avoiding these particular situations. Individual patients have
different situations," which I totally agree with -- appropriateness
criteria guidelines are just a starting place. But the fact that
there's
such marked variability between hospitals tells you and I that
there are
opportunities for improvement.
Q: What are some actions, going forward, that can reduce the higher
inappropriate figures for some hospitals for stable non-acute indications?
Dr. Brindis: The point here is Peter Drucker's famous line: "If
you don't measure it, you can't manage it." So here for the
very first time, EVER, somebody has figured out appropriateness
criteria.
We're now measuring it and, as of last quarter, we're beginning
to feed
this data back to the hospitals in benchmark form. So prior to
this quarter, no on even knew what they were doing. Now they're
going
to know. Again the right answer isn't to be 100% appropriate. We
talked about individual patient-physician relationships -- every
patient's different. But if you were a hospital and your appropriateness
rate in stable angina patients was 50% and the national average
was 90%, you would have to ask yourself, “Should we be looking
at how we take care of patients, particularly, appreciating that
there's going to be a new payment model, that's going to be ACOs
(Accountable Care Organizations)?” And in an ACO model when
you start having issues of global payments, or other payments related
to an ACO model, people are going to be looking at this. So this
affords physicians, hospitals and again new models of care delivery
to be able to examine what their practice patterns are and opportunities
for improvement.
Q: A very important mission
for us at Angioplasty.Org is to communicate to patients the
importance of recognizing the
symptoms
of a heart
attack and then getting to a hospital that performs angioplasty
ASAP, because a heart attack is no longer a “done deal” – it
can be stopped.
Dr. Brindis: This is a continued opportunity for community education
by the ACC, AHA to make sure balance and important messages get
through to patients. There are lots of reasons for patient delay
to seeking
care: embarrassment, concern over the cost of ambulance, denial
of symptoms, all sorts of reasons, and your comment is on target.
And
God forbid that this particular issue about concern of inappropriate
stenting further complicate all the typical normal human social
barriers that we already have in terms of delivering timely angioplasty
for
patients with acute coronary syndromes.
Q: Finally, there was some mention
of Fractional Flow Reserve (FFR) and other measurement modalities
of determining
appropriateness
of PCI – although FFR is something done during the angiogram.
Do you think there’s a role for FFR and functional measurement
in determining appropriateness?
Dr. Brindis: My own personal feeling and bias is that FFR is an
extremely important tool and that it hopefully will increasingly
be utilized
in terms of appropriate decision-making related to PCI going forward.
And I also predict that, as we come up with different payment models,
particularly related to disease-bundling or episodes of care, that
it will become even more encouraged at the local hospital level,
so that a stent is put in, after a demonstration of ischemia, particularly
in intermediate lesions. I will say that within my own institution
at Kaiser Permanente, we are finding increasing value in the use
of FFR at the time of catheterization for decision-making.
1 Appropriateness
of Percutaneous Coronary Intervention ; JAMA. 2011;306(1):53-61.doi:10.1001/jama.2011.916
This interview was conducted in July 2011
by Burt Cohen of Angioplasty.Org.
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