SCAI Pokes ABIM Again, This Time Over Procedural Volume Requirements

Interventional cardiologists are again pushing back on requirements for maintenance of certification (MOC) as mandated by the American Board of Internal Medicine (ABIM), specifically requesting a sunset of procedural volume thresholds.

Currently, the ABIM requires physicians to complete 100 PCIs or equivalent procedures over 2 years, while also offering a lower-volume alternative of 25 consecutive primary operator procedures accompanied by a thorough outcomes report.

Last month, the Society for Cardiovascular Angiography & Interventions (SCAI) held a town hall and published a draft position statement aimed at changing the way interventional cardiologists maintain their certification. The public comment period for the statement is open through today, after which the society plans to integrate feedback and publish it in JSCAI.

This isn’t the first time SCAI has challenged the way the ABIM runs its MOC process, with a successful advocacy initiative to remove the costly and cumbersome recertification exam mandated every decade as well as more recent efforts to try and do away with MOC entirely.

While once beneficial in a nascent field, procedural requirements no longer ensure safety but are rather a burdensome task for most physicians, argue SCAI leaders.

SCAI President-Elect Joaquin Cigarroa, MD (Oregon Health & Science University, Portland), told TCTMD that not only have procedures become safer over time, but also the field has “formalized several components that emphasize competency as opposed to knowledge-based [certification]. We believe that the ABIM is heavily involved and capable in assessing knowledge base and MOC; they do that really well with testing. The local credentialing process and the registry reporting really is where we believe that the assessment of competency should occur.”

Outcomes-based evaluation is more valuable than procedure counts, he emphasized. “Procedure counts at an individual level tell us nothing. If they did tell us something, one would think that the ABIM would apply this across every subspecialty in the ‘House of Medicine.’”

For example, other procedural-based fields like gastroenterology and electrophysiology do not currently have procedure counts that are mandated by the ABIM, nor do any other specialties within the internal medicine umbrella. 

“When interfacing with the ABIM, they stated that we in the field of interventional cardiology asked for the procedural counts, and that is true,” Cigarroa said. “We did back in the 1990s when the field was immature.” Now, though, registry and outcomes data have shown time and again that PCI volume does not affect outcomes such as MACE and mortality for experienced operators.

Modern measures of competence, mostly conducted at the local level, like Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE), as well as hospital credentialling, serve as viable ways of ensuring quality, he added.

Reason for Attrition?

In trying to understand some of the drivers of attrition within the field of interventional cardiology, SCAI President J. Dawn Abbott, MD (Brown University, Providence, RI), told TCTMD that many later-career physicians move into hybrid roles “where they do a lot of general cardiology, and their volume may not be very high, but they’re really providing high-quality, necessary care in their community.” Additionally, she added, “end-of-career individuals who have the most interventional experience may be most vulnerable to these types of ongoing procedural requirements as they try to break away from performing these procedures to have more controlled schedules or move more into consultative practice.”

Procedural volume requirements are not meeting the needs of the field, and they aren’t improving quality of care, she argued. “We’re looking at a requirement that is introducing barriers at different phases of people’s careers without a clear indication that it’s actually beneficial to the public or to our interventional field, and this is why we really need to address it,” Abbott said.

During the town hall, SCAI leadership presented results of a survey it conducted, including 389 responses. Almost half (47%) of respondents worked in academic medical centers, with another 42% working in community hospitals, 22% in private practice, 12% in integrated health systems, 3% in rural or low-volume practices, 5% in Veterans Administration hospitals, and 2% in other. The majority of respondents (89%) were focused in coronary interventions, with about one-third each in structural heart and peripheral vascular interventions. Career duration was well represented, with the largest cohort (34%) having 10-19 years of experience. Also, most respondents (77%) were actively performing interventional procedures. Notably, while 25% of respondents complete more than 250 cases annually, 13% complete fewer than 50.

Almost half of respondents (48%) said they needed to submit a reviewed procedure log to the ABIM in lieu of providing straight procedural numbers. The estimated time to compile and submit the procedure log ranged from fewer than 2 hours (22%) to more than 10 hours (16%). 

A full 73% of respondents felt that procedural volume requirements are not necessary for patient safety. Moreover, only 6% of respondents said that procedural volume is a “very meaningful” measure of competence alone, with 27% saying it is “not meaningful at all” and another 31% saying it is “not very meaningful.” Seventy one percent of respondents agreed or strongly agreed that procedural volume requirements negatively affect patient access to interventional cardiology care in rural, underserved, or low-volume settings.

Most respondents (90%) said their health system uses hospital credentialing or privileging to evaluate competence or performance; 74% have morbidity and mortality review; 72% undergo peer review; and 50% each use OPPE, registry-based benchmarking or outcomes review, and quality-improvement participation. Also, 87% of respondents said their health system participates in national or regional registries or local quality review, with 68% saying these were very or somewhat meaningful to assess ongoing procedural competence.

Regarding concerns that physicians have about the current volume requirements, 74% said it doesn’t accurately measure competence, 72% said it may disadvantage physicians in low-volume or rural settings, 67% said it may disadvantage physicians with other interventional or academic focuses, and 64% said it creates administrative burden.

Looking Back

Speaking during the town hall, Theodore Bass, MD (UF Health, Jacksonville, FL), who was active in designing the initial interventional cardiology credentialing process with the ABIM, said there was “no science behind” measuring procedural quality among operators when the field first was established. The number chosen of 50 was “imperfect” and had “very little validity,” he acknowledged, adding that he and his colleagues thought other measurements like quality assessments would come into play along the way.

“It’s not surprising because the ABIM was really a certification process for internal medicine and subspecialties, and now we’re dealing with a procedure, and we’re trying to apply some of the similar metrics that we would use to judge anything to a relatively evolving procedural process. And I think we were off base with that,” Bass said.

Procedural volume numbers “were meant to be just suggestions, not strict guidelines, and they weren’t to be used for credentialing,” he said. “But of course we weren’t completely stupid. We knew they would be, and that’s how we got into this mess.”

Coming full circle, Bass said that though he’s retired, he occasionally does “locums just to keep my hand in [the field], and I work in rural hospitals because I figured at this point in my career I didn’t need residents and interns. I just wanted to work on patients to see what it was like. And now I’m having trouble getting any assignments because I’m not keeping my numbers up.”

One mistake the credentialing team made was not taking into account lifelong case numbers, he said. Ultimately, “it’s a very silly metric and I completely support the direction that the group is going, and it’s about time.”

With respect to rural settings especially, Bass said competency should be defined by whether “the practitioner knows what they don’t know or what they shouldn’t be doing, and that has very little relationship to numbers.” This is why rural STEMI programs have been able to successfully serve patients, he added. For those specifically, the balance has long been between making sure these programs can exist with competent physicians and also providing checks that ensure they’re working as they should. 

Next Steps

Abbott said that once the statement is officially published, she’d like to see a larger survey go out and efforts to increase awareness of this initiative within the field. “Hopefully we can get enough board-certified interventionalists to understand the implications of the requirement, and hopefully with favorable responses, then the ABIM will take the requirement out of effect,” she said, adding that she would expect the process to take about a year.

Cigarroa agreed. “I think that it would be a positive step for the ABIM to survey their own landscape, to listen to SCAI, review the data that has been presented through peer-reviewed published articles by individuals who are experts in this field, and drop the requirement,” he said. “If they felt that the requirement of procedural numbers at an individual level were valid, why would they not apply them to every other procedural area in internal medicine and the associated other specialties?”

 The issue at stake is not about whether interventional cardiology needs quality physicians who can provide optimal care, Cigarroa said. “We care deeply about making sure that practitioners have the opportunity to care for patients, even in the period when an interventional cardiologist chooses to continue to care for patients but stop doing procedures and to be available.”

He underscored that “we are completely aligned on mechanisms to support ongoing acquisition of knowledge and the associated infrastructures at a local level and national level to support the delivery of high-quality care and to support the individual practitioner with the data that they need and the structure and processes to participate in to make sure that our patients and our clinicians can do so.”