Why Is My Lab’s PCI Volume Decreasing?

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Morton J. Kern, MD, with contributions from Drs. Carl Tommaso, Peter Ver Lee, Gregg Stone,
Mladen I. Vidovich, Lloyd W. Klein, Bonnie Weiner, Ted Bass, Jimmy Tcheng, Kirk N. Garratt,
Aaron Kaplan, Samuel M. Butman, John Bittl, John W. Hirshfeld, Jr., Michael Lim, and Greg Dehmer

In this “Conversation in Cardiology,” Dr. Carl Tommaso asks, “Since 2006, the number of percutaneous coronary interventions in the United States is down 39% (963,000 procedures in 2006, 589,000 in 2010), with an estimated 10-15% decrease in each of 2011 and 2012.”

What do you feel are the reason(s) for this? 

  1. Bad publicity given to interventional cardiology, because of suspected cases of fraud and abuse.
  2. Cardiologists focusing on structural heart disease rather than coronary disease.
  3. COURAGE trial results: increased use of medical therapy.
  4. Decreased reimbursement.
  5. Fear of RAC audits.
  6. Implementation of Appropriate Use Criteria.
  7. Increased affiliation of cardiologists with hospitals, reducing fee-for-service incentive.
  8. Patient wariness about undergoing invasive procedures.
  9. Reduction in the incidence of coronary disease.
  10. Referring physicians (internists and non-invasive cardiologists) less likely to refer for cath and intervention.
  11. Other.

I circulated this question to my list of cath lab experts and provide their answers for you here. As with all our conversations, these are the opinions of the authors and published with their permission. At the end of the discussion, there is synopsis and review by Dr. Tommaso, who posed the problem to us. 

Mort Kern from Long Beach, California:
My view is that the reduction is of course multi-factorial, but weighted to the following: 1) Appropriateness and fear of consequences; 2) COURAGE trial erroneous conclusions; 3) Purchase of medical groups and reduction of fee-for-service incentivization; 4) Success at coronary artery disease control and reduction through societal behavior and medical treatment.

Peter Ver Lee from Maine:
Our own volume has decreased by 17% over this time. We have a stable, captive population. Because of our geography, very few patients in our service area go to heart centers with PCI capability elsewhere in Maine and fewer go to Canada. The number of interventional doctors and cath labs has not changed. We have always practiced according to what I would call a traditional, conservative, New England style.

I think the main reason for the decline in volume is the wider penetration of statin use, better risk factor control and the emergence of drug-eluting stents. Our conservative style is perhaps the explanation for the lower fall in volume as a percentage. We started out at a lower point and had a shorter distance to fall. In the last few years, however, the volume has been much flatter, only 2-3% decrease annually.

Greg Dehmer from Temple, Texas:
In some respects, the decrease is an example of “Little’s disease”: a little bit of this and a little bit of that or, in other words, it is related to many of the 10 factors listed. I do think Mort’s top 4 are the largest factors. 

If you start in 2006, we also need to consider the effect of drug-eluting stents reducing the occurrence of restenosis, despite the chaos of late 2006 and the hype over stent thrombosis. We are now down to single-digit rates of restenosis.

Gregg W. Stone from New York City:
The decrease is not that bad, but still concerning (and misguided) (see Figure 1).

Mladen I. Vidovich from Chicago, Illinois:
Clearly, we have a demographic transition with increase in the older population (Figure 2) and a concurrent epidemiological transition of declining prevalence of CAD (Figure 3). In a ballpark unadjusted look, it appears that there are other factors in play beyond just simple secular trends. Perhaps the cumulative number of diagnostic cath/PCI over time impacts its future use/penetration, but we need a good statistician/epidemiologist to confirm that.

Lloyd W. Klein from Chicago, Illinois:
I also agree that access to care is probably the number-one factor. Note that Gregg’s graphic takes a dip just when the economy did, in 2008. People lost their jobs, and with that loss, insurance.

Another factor is the aging of our population and a shift to federal government-paid insurance. I do not think that many of the laudable reasons why the PCI volume maybe ought to have decreased is the reason why it did. Once the patient gets into the system, there are good reasons and bad ones why it is tough to keep them out of the lab and a stent from being deployed, but I believe the bad ones typically win out in usual practice. Sorry, I am a cynic.

Although some primary doctors see themselves as the patient’s protector, and keeping them away from us is their primary goal, I do not think this works so often as to explain Gregg’s graphic (Figure 1). My guess is that repeat procedures over this time frame are decreasing. What used to be an “annuity” is now quite uncommon.

Bonnie Weiner from Worchester, Massachusetts:
 In the current economy, there is a general sense, now apparently corroborated, that patients are not accessing the health care system as much. Probably due to multiple factors, but including concern over taking time off, even if they have health insurance, not having insurance, or not having jobs where dollars are prioritized elsewhere. One would think that ultimately that would result in an increase in acute procedures. There may be significant geographic variation in this and warrants further inspection.

Ted Bass from Jacksonville, Florida:
I have attached the AHRQ data (see Table 1). There has been some question that the counting methodology has changed since the peak years in the mid-2006 era, eliminating some “double dipping” on single cases. There are Centers for Disease Control data out there suggesting a less robust, but still significant, decline in procedure volume. I have also attached CMS data and an interesting paper involving many of the issues you bring up. It is hard to get one’s hands around the actual number, but appropriateness analysis seem to imply that currently well >70% of PCI are in the non-elective (ACS) setting and the decrease in numbers probably related to a falloff in the elective cases, suggesting many of the reasons you list might be on target.

Riley et al1 confirms recent speculation that PCI volume has begun to decrease. Although rates of CABG have waned for several decades, all forms of coronary revascularization have been declining since 2004. This all has very interesting implications on training volume numbers, competency and certification volume requirements, and manpower distribution, as well as patient access to primary PCI, etc.

Carl Tommaso from Chicago, Illinois:
Figure 4 (source: Wayne Powell, SCAI) shows procedural frequency of the last few years. This data eliminates the double counting that plagued the earlier numbers.

Gregg W. Stone from New York City:
This “double-counting issue” has never been completely explained, or at least it doesn’t seem to have made an impact on other data sources. As you can see, industry sources and hospital marketing data keep coming up with much higher numbers.

Jimmy Tcheng from Raleigh, North Carolina:
I would add cigarette taxes, and the resulting drop in tobacco consumption, to the list of contributors to the reduction. Better medications, advancing technologies (DES), greater compliance, improved imaging, clinical trials science, AUC / Hawthorne effect, and administrative (counting) issues round out my list.

Kirk N. Garratt from New York City:
It seems the decline has been most pronounced in elective patients, but I sense the rate of ACS PCI is down some, too. Ted, you hit an important item: maintaining competency is harder than ever if it’s just a numbers game. At my place, the shoe pinches most around emergency cases. State regulations say you need 75 cases, of which 11 are emergencies, to maintain competency. In a hospital with a dozen interventionalists and corralled by PCI-capable places, it’s tough to come up with enough acute patients. 

Aaron Kaplan from Lebanon, New Hampshire:
I would add dual antiplatelet therapy (DAPT) confusion. This is defined as confusion/concern on the part of patients and their primary physicians over DAPT management. As a group, I do not believe the interventional community is doing a good job supporting our primary care/referring physicians (PCP) regarding DAPT. As a result there are many patients on indefinite DAPT. Without our clear guidance, the PCP is in a real bind and frets when confronted with a situation that may require discontinuation. This adds complexity and anxiety on the part of the PCP, driving a more conservative approach when managing these patients.

Samuel M. Butman from Arizona:
My thoughts (as I am a bought physician working for a hospital) are that the decrease in volume is due to: 1) Cardiologists focusing on other things rather than coronary disease, more cardiologists (not pointing at you or me directly) sitting at their desks doing computer EMR, CPOE entry instead of getting radiated; 2) Decreased reimbursement; 3) Increased affiliation of cardiologists with hospitals, reducing fee-for-service incentive; 4) Reduction in the incidence of coronary disease.
Coronary heart disease is on the decline and that may be countering the groundswell of excitement about the expected growing baby boomers, i.e. you and I, yet again. In addition, I think docs are retiring earlier and more are looking at other business platforms, be it in medicine or outside (property, spouse working, less divorce activity so less need to make more money than is reasonable (yes, I made up the last one).

John Bittl from Ocala, Florida:
For a look at larger trends in medicine, please see the article entitled, “Doctor Visits Dropping, New Census Figures Show.” This was written by Sabrinia Tavernise and published in The New York Times on October 1, 2012. It states, “Americans of working age are going to the doctor less frequently than they were 10 years ago, according to a new report by the Census Bureau. In 2010, people age 18 to 64 made an average of 3.9 visits to doctors, nurses and other medical professionals, down from 4.8 visits in 2001, said the report, which was released on Monday. The precise reasons for the decline were unclear...”

Chih-Lu Hansays: December 10.2012 at 01:24 am

I am an active interventional cardiologist in Taiwan. I have seen similar trend in Taiwan as well. I can propose few possible explanations:
1. Too many catheterization laboratories in Taiwan! More than 90 hospitals providing coronary intervention service in such a small island.
2. The prevalence of coronary heart disease in Chinese is not as high as the western countries!
3. Popular use of DES! Less recurrent stenosis following PCI.
4. Ageing of population! The aged people comes with more complex coronary atherosclerosis which is too risky or inappropriate for coronary intervention! And the aged often prefer less risky medical therapy instead of coronary artery surgery!

The infamous Taiwanese universal health care system is trying to promote the use of FFR. Soon the patients can get reimbursement of using those relatively new diagnostic modality. This definitely will reduce abused stenting.

Reply to this comment »
Morton Kernsays: December 10.2012 at 12:30 pm

Thank you Dr. Han,
Your comment is enlightening and in keeping with what is discussed by my colleagues in the article. I do applaud the Health Care system recognizing the value of FFR and incentivizing the use of appropriate tools for best outcomes.

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