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Newly updated recommendations from the American College of Cardiology (ACC), American Heart Association (AHA), and Society for Cardiovascular Angiography and Interventions (SCAI) assert that operator volume is only one of many benchmarks that should be used to evaluate the quality of percutaneous coronary intervention (PCI). The joint statement was released at the SCAI annual meeting in Orlando, FL, and published online May 8, 2013, ahead of print in the Journal of the American College of Cardiology, Circulation, and Catheterization and Cardiovascular Interventions.
Created under the guidance of writing committee chair and ACC president John G. Harold, MD, of Cedars-Sinai Medical Center (Los Angeles, CA), the report outlines the core competencies and technical skills required in contemporary practice.
Competence Decidedly Multifactorial
SCAI president Theodore A. Bass, MD, of the University of Florida College of Medicine (Jacksonville, FL), who served as vice chair of the writing committee, told TCTMD in a telephone interview that the new advice is a timely update to the 2007 Clinical Competence Statement on Cardiac Interventional Procedures.
“It’s been 6 years, and things have changed,” he said. Cardiovascular medicine has evolved, as has the field’s “appreciation that competence is a little bit more complicated to evaluate and achieve than just, for example, knowing the correct answer on a test.”
Dr. Bass stressed that “physician competence is one of the central cores of providing quality health care. It should be addressed comprehensively and in a very serious way.”
In a telephone interview, Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), told TCTMD that practicing cardiologists will pay close attention for 2 main reasons: quality metrics affect how hospitals credential physicians and also influence perceptions of accountability in medical malpractice lawsuits.
The document lists 6 areas that comprise operator competence:
Volume Not a Stand-in for Quality
However, the topic most likely to gain attention is reduced emphasis on operator volume, Drs. Brener and Bass both noted.
The ACC/AHA/SCAI report sets the bar at 200 cases per year for institutional volume and—in a shift from earlier advice—lowers operator volume from 75 to 50 cases annually, averaged over a 2-year period.
“The writing committee cautions against focusing on specific volume recommendations and emphasizes that procedural volume is 1 of several variables to consider when determining operator competency. Volume is not a surrogate for quality and should not be substituted for risk-adjusted outcomes and other measures of quality,” Dr. Harold and colleagues write, noting that case review and ascertainment of appropriateness should be performed periodically to judge the quality of all operators and institutions, even those whose volumes exceed recommended thresholds. Participation in local or national registries is also helpful, they add.
Dr. Bass said, however, that the lower threshold for operator volume should not detract from discussion of other, perhaps more important aspects of competency including “what [clinicians] know, how they practice, how they integrate into complex medical systems, how they deal with data, how they relate to peers and patients and healthcare personnel, and how they keep up to date on things.”
“In the past,” he noted, “volume has always been a surrogate for competency, because it was measureable. It’s intuitive that if someone does [something] more, they’ll be pretty good at it. There are some data to suggest there is a relationship, but the correlation isn’t as strong [as had been thought]—especially when it comes to individual procedural numbers.”
The evidence for a threshold is more convincing on an institutional level, Dr. Bass said. “Again, it’s not the be-all and end-all. There are cath labs that are under that volume, and as long as they’re striving toward quality and measuring it and making sure they’re installing processes to ensure the continuing deliverance of quality, that could be acceptable.”
Societal needs, such as STEMI care in underserved rural regions, must be weighed against strict cutoffs, Dr. Bass commented.
According to Dr. Brener, the shift away from firm recommendations is a welcome recognition that the relationship between volume and quality is “complicated.”
Another issue is how these standards will play out in the real world, he said. “To go to these people [with low volume] and tell them, ‘Okay, we’re going to take your license away,’ I’m not sure it will work.” In the era of appropriateness criteria, the solution is not to perform more cases, Dr. Brener urged. “There is already intense scrutiny. . . . It’s not so simple.”
Dr. Bass agreed that a “rush to volume” would be ill advised.
Radial Access Highlighted
As a consensus document integrating many perspectives from many subfields, the ACC/AHA/SCAI statement will likely spark some disagreement, Dr. Bass acknowledged, though he seemed reluctant to draw attention to specific points that might be divisive. Instead, he encouraged physicians to read the statement with fresh eyes.
Among the various topics addressed, Dr. Brener praised the emphasis placed on radial access. The section devoted to the technique took up nearly as much space, for example, as the one discussing volume as a surrogate for quality. “The data on radial are very interesting and something that people need to pay attention to,” he commented.
Radial access “is an older technology that’s just now coming into use in the United States,” despite being common internationally, Dr. Bass noted. The portion of procedures performed radially is growing so rapidly, he said, that the “thought was, let’s put it out there. It will have to be addressed more substantially in the future.”
The joint statement also includes information on other coronary interventions such as alcohol ablation and fistula closure as well as specific approaches for quality assurance.