Cath Lab Digest

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.