Editorial Calls for ‘Real Value’ in Interventional Cardiology

An editorial published online February 4, 2014, ahead of print in Catheterization and Cardiovascular Interventions argues that interventional cardiologists should weigh not only appropriateness but also clinical and patient expectations and financial cost when making treatment decisions.

Peter L. Duffy, MD, of Reid Heart Center/FirstHealth of the Carolinas (Pinehurst, NC), presents the concept of ‘Real Value’ as a mathematical formula with 4 parameters: clinically-defined outcomes plus patient expectations divided by relative cost, all multiplied by appropriateness.

Interventional cardiologists “must prove that we add real value to our health care system,” he writes. “It is no longer good enough for us to just do our work and expect it to be appreciated.”

A Tool for Real-World Use

Dr. Duffy argues that the Real Value approach helps address the inadequacies of the Appropriate Use Criteria (AUC), first released by the American College of Cardiology Foundation, American Heart Association, and other professional societies in 2009. According to the AUC, “[c]oronary revascularization is appropriate when the expected benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of life), exceed the expected negative consequences of the procedure.”

In a telephone interview with TCTMD, Dr. Duffy said that the Real Value formula moves beyond ‘appropriateness’ by allowing clinicians to document why a given option may not meet AUC but is still the right choice for a particular patient.

The clinical tool “allows you to go back and evaluate not only your work but oversee other people’s work, too. It’s a good educational process,” on both departmental and institutional levels, Dr. Duffy suggested. He recommended that clinicians ask themselves:

• Did I use my resources appropriately?
• Is this really what the patient thought was going to happen?
• Did I get what I wanted?
• How appropriate was it?

On a daily basis, the formula can help physicians rank various competing factors in decision making, Dr. Duffy said, “so that we have more consistency in care.”

AUC Limited but Evolving

In a telephone interview with TCTMD, Gregory J. Dehmer, MD, of Texas A&M University Health Science Center College of Medicine (Temple, TX), said, “I don’t know if this [particular] formula will carry us into the future, but the concept that Dr. Duffy puts forth in this is very important, because everyone knows that health care in the United States is undergoing dramatic change. Patients indeed are becoming more value conscious as more of [the cost of] health care is put on their shoulders.”

Dr. Dehmer, who has served on the 2009, 2012, and 2014 AUC writing committees, acknowledged that the quality metric of ‘appropriateness’ has shortcomings. “If we were going to include every possible factor that a heart surgeon or interventional cardiologist needs to put in the equation to decide what to do, there would be over 4,000 different clinical scenarios,” he said. “Then the [AUC] would be as thick as the New York City phonebook, and people would say, ‘How can we possibly use this? It’s enormous.’”

The latest version of the AUC is currently being developed and will hopefully provide a balance between ambiguity and explicitness, Dr. Dehmer noted. In the meantime, the current editorial correctly recognizes that ‘appropriateness,’ however imperfect, “does need to be considered,” he said.

In an e-mail communication with TCTMD, Kishore J. Harjai, MD, of Geisinger Wyoming Valley (Wilkes-Barre, PA), agreed that the AUC, though “a good first step,” require improvement.

“[They are] difficult to retrieve, not [electronic medical record] friendly, often controversial, lagging behind evidence, and frequently based entirely on ‘expert’ consensus. Even when evidence exists [to the contrary], the published AUC documents do not provide supporting references for the skeptical clinician. Yet, I have no doubt that AUC will continue to evolve and become the de facto standard of care in cardiology and other specialties,” he concluded.

A Formula Not the Solution

However, Dr. Harjai expressed skepticism about the Real Value formula. “Promulgating variations of the Value equation is an intellectually futile exercise,” he emphasized. “We are in the midst of a huge crisis: overspending 1.2 billion Medicare dollars every day. We cannot rectify this unsustainable situation with further debate on what constitutes ‘value.’”

“Rather, we need an urgent 3-pronged political solution to the runaway costs,” Dr. Harjai suggested.

An individual must be appointed at a national level to guide healthcare policy and reform, Dr. Harjai proposed. “By nature, change is unpopular, and cannot be brought about by officials worried about their next election.”

In addition, he said, “We have seen a huge focus on reimbursement to doctors and hospitals but a lack of political will to tackle other elements that contribute to escalating costs.” Thus, to be comprehensive, cost-reduction strategies need to recognize that both malpractice lawyers and for-profit industries including drug and device manufacturers play key roles in the expense of the healthcare system, he stressed.

Finally, patient expectations must be managed, Dr. Harjai stated. “[D]eveloped countries that have succeeded in controlling healthcare costs have done so by the rationing of healthcare explicitly approved by society. In the United States, we try to reduce healthcare costs through controls on healthcare providers,” he explained. “This is untenable. Providers cannot be expected to serve as gatekeepers in a society addicted to healthcare consumption.”

 

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Source:
Duffy PL. Real value: A strategy for interventional cardiologists to lead healthcare reform [editorial]. Cath Cardiovasc Interv. 2014;Epub ahead of print.

 

 

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