Results of the society of cardiac angiography and interventions survey of physicians and training directors on procedures for structural and valvular heart disease

Background: Minimal information is available on the number and type of procedures being performed for structural and valvular heart disease, the physicians who perform these procedures, and on the training requirements for this emerging field. Methods: Surveys were performed using an online survey of members of the Society of Cardiac Angiography and Interventions (SCAI), including its Council on Structural Heart Disease and the Congenital Heart Disease Committee. The responses of 107 US‐based interventional cardiologists were analyzed. A second questionnaire of a purposive sample of 10 training directors of US interventional cardiology programs was also performed. Results: Although many procedures (e.g., transseptal puncture, PFO, and ASD closure) are commonly performed by most respondents, others are limited to a significant minority of respondents (e.g., alcohol septal ablation, transcatheter valve repair, and implantation). In addition, the number of procedures performed varies greatly as does the training directors' estimate of the number necessary to gain proficiency. There is no single method being used to gain the requisite skills. A number of factors that limit the more widespread growth of this field were identified. Conclusions: The field of intervention for structural and valvular heart disease is new, growing rapidly, and will require a core knowledge base and new didactic methods. The cardiovascular community will be challenged to devise new training standards and credentialing approaches to serve interventionalists interested in this field. © 2010 Wiley‐Liss, Inc.     

Economic Credentialing

In the 1990s, hospital management and trustees introduced the concept of evaluating physicians for appointment, reappointment, and privilege delineation with the addition of financial criteria. Although emergency physicians are advocates for cost-effective care, they must make certain that credentials are determined by the provision of quality medical care, and that if economic criteria are used, the criteria chosen truly reflect quality of care. [Schafermeyer RW: Economic credentialing. Ann Emerg Med December 1997; 30:759-764.]     

Continuous practice and advanced training in interventional cardiology. Recommendations for the assessment and maintenance of proficiency in interventional cardiology. A statement for physicians and advanced training units from the Section of Hemodynamics and Interventional Cardiology of the Spanish Society of Cardiology

This report reflects the interest of the Section of Hemodynamics and Interventional Cardiology of the Spanish Society of Cardiology in increasing quality, safety and applicability of percutaneous procedures, by giving scientific keys aimed at improving related functions of teaching or planning in this field and enhancing competence and prestige of Spanish interventional cardiologists. The purpose of the document is to describe the importance of current interventional cardiology, to identify quality references and to establish minimum acceptable requirements for assessing and maintaining the competence of practicing or providing advanced training in this discipline. To achieve this goal, a search for a gold standard of the different techniques of general interventional practice was carried out, and predictors of postprocedural outcome were analyzed, as well as their relation with different kinds of circumstances. This analysis identified coronary angioplasty as the standard on which recommendations regarding competence in overall interventional cardiology standards of quality and assessment and maintenance of proficiency must be based. On the other hand, the strong influence of experience and knowledge of results has been documented, especially in high-risk or high-complexity settings. On this basis, the report establishes specific recommendations about proficiency for practice and advanced training. It also suggests that interventional cardiology should be considered as a subspecialty, of cardiology requiring specific credentials.     

ICU procedures of the critically ill

Intensive Care Unit (ICU) patients often require urgent, high-risk diagnostic and therapeutic procedures. However, they are particularly vulnerable to procedural complications due to the severity and instability of their illnesses. We discuss the complications associated with bronchoscopy, percutaneous dilatational tracheostomy, pleural interventions for example thoracentesis and chest tube placement, central venous catheterization and pulmonary artery catheterization. Invasive procedures are frequently performed in critically ill patients. It is important for the operator to be familiar with the specific complications of each procedure, as well as steps to take in order to enhance safety and reduce adverse events. High standards of training and credentialing are crucial to ensure that the ICU physicians are proficient in performing these procedures.     

America's Health Care System is Broken: What Went Wrong and How We Can Fix It. Part 3: Hospitals and Doctors

Thirty-two percent of US health care spending goes to hospital care, and 20% goes to physicians’ charges. The cost of hospital care in the United States is 2-3 times greater than in most similar countries. A large part of the high cost is due to a very large administrative overhead. Both higher quality and lower cost would be achieved if complex procedures were done in fewer centers. Hospitals with a geographic or prestige monopoly receive higher payments than warranted. As physicians are increasingly employed by hospitals rather than independent, costs go up with no added benefit to patients. The United States has too many specialists and too few primary care physicians. Practice guidelines are slanted to favor expensive treatments, often with little solid evidence behind the recommendations.     

Procedural skills of the general internist. A survey of 2500 physicians

STUDY OBJECTIVE: To determine which of 40 clinical procedures general internists do in their practice, how often these procedures are done, and what training is needed to develop and maintain competence in each. DESIGN: Mailed survey. PARTICIPANTS: A random sample of 2500 American College of Physicians (ACP) members identified as general internists; 1806 (72%) responded. Of these, we excluded 398 who were board eligible or board certified in a subspecialty and 143 with unknown status. The resulting sample of 1179 was augmented in selected analyses by an additional sample of 199 rural internists. RESULTS: General internists did, on average, 16 of the 40 procedures. Practice characteristics markedly affected the number and variety of procedures done. A larger number of different procedures was independently associated with smaller cities, smaller hospitals, younger age, increased hours in patient care, and certain regions of the country. Practice characteristics varied considerably by practice type and location. Many procedures were done infrequently. There was reasonable agreement on the experience needed to attain and maintain competency in each procedure. The majority of respondents favored hospital credentialing for 22 of the 40 procedures. CONCLUSIONS: General internists do a wide variety of procedures, the number and frequency of which are affected by the characteristics and location of their practice. Despite opinion to the contrary, more recently trained general internists do a wider variety of procedures than older colleagues. These results provide data to help define standards for training and credentialing and suggest that we should reexamine general internists' training in procedural skills.     

The influence of public reporting of outcome data on medical decision making by physicians

BACKGROUND: Public disclosure of physician-specific performance data is becoming increasingly common. However, the influence that public reporting of outcome data has on the delivery of care by physicians who are being assessed is not well understood. METHODS: Since 1994, the New York State Department of Health has collected and periodically published observed and risk-adjusted patient mortality rates for all interventional cardiologists practicing coronary angioplasty in the state. To assess the influence that these reports exert on the physicians being monitored, a questionnaire was administered in an anonymous manner to all interventional cardiologists included in the most recent report. RESULTS: The vast majority (79%) of interventional cardiologists agreed or strongly agreed that the publication of mortality statistics has, in certain instances, influenced their decision regarding whether to perform angioplasty on individual patients. Physicians expressed an increased reluctance to intervene in critically ill patients with high expected mortality rates. Among the respondents, 83% agreed or strongly agreed that patients who might benefit from angioplasty may not receive the procedure as a result of public reporting of physician-specific patients' mortality rates. Additionally, 85% believed that the risk-adjustment model used in the Percutaneous Coronary Interventions (PCI) in New York State 1998-2000 report is not sufficient to avoid punishing physicians who perform higher-risk interventions. CONCLUSIONS: Public reporting of physician-specific outcome data may influence physicians to withhold procedures from patients at higher risk, even when physicians believe that the procedure might be beneficial. This phenomenon should be recognized in the design and administration of physician performance profiles.     

Evaluating RT services by internal audit

The quality of services provided by respiratory therapists must be measured as part of a hospital's overall evaluation of patient care, as mandated by the Joint Commission on the Accreditation of Hospitals. An internal audit helps both the respiratory therapists and the attending physicians to know what kind of specific documentation is needed in the medical records to meet the desired standards. It also serves as a useful tool in identifying staff educational needs.     

The changing landscape of interventional cardiology: A survival guide in the era of health system consolidation

Practice environments for interventional cardiologists have evolved dramatically and now include small independent practices, large cardiology groups, multispecialty groups, and large integrated health systems. Increasingly, cardiologists are employed by hospitals or health systems. Data from MedAxiom and the American College of Cardiology (ACC) demonstrate an exponential increase in the percentage of cardiologists in employed positions from 10% in 2009 to 87% in 2020. This white paper explores these profound changes, considers their impact on interventional cardiologists, and offers guidance on how interventional cardiologists can best navigate this challenging environment. Finally, the paper offers a potential model to improve the employed physician experience through greater physician involvement in decision making, which may increase jobs satisfaction.     

Management of acute coronary syndromes, a questionnaire survey of the clinical practice of cardiologists and other medical physicians belonging to west midland hospitals

OBJECTIVE: To assess the management of acute coronary syndromes by cardiologists and other medical physicians in a clinical setting. DESIGN: Questionnaire survey consisting of 10 hypothetical clinical scenarios and four possible therapeutic options for each scenario. SETTING: Consultants and specialist registrars in Cardiology (with or without access to interventional facilities) and consultant physicians belonging to various hospitals in the west midland region of United Kingdom. MAIN OUTCOME MEASURES: Respondents' ability to recognise high risk patients and their management of the hypothetical clinical cases. To establish any differences in management strategy between cardiologists and general physicians, and whether these differences, if any, relate to access to interventional cardiac facilities. RESULTS: Overall no significant differences were found in the responses between cardiologists and general physicians with or without access to cardiac interventional facilities. However, cardiologists were more inclined to use percutaneous transluminal coronary angioplasty (PTCA) compared to other physicians (scenario 8, 18.4% vs. 6.7%, p = 0.05 and scenario 9, 44.9% vs. 26.7%, p = 0.01). In two other situations, physicians from institutions with access to interventional facilities were more inclined to use 'other' treatment strategies (intravenous nitrates, antiplatelet treatment, inotropes, Intra-aortic balloon pump) compared to their colleagues from non-tertiary hospitals with no interventional facility on site (scenario 3, 21.7% vs. 2.4%, p = 0.04) and more use of PTCA ( scenario 6, 52.2% vs. 26.8%, p = 0.04). CONCLUSIONS: The management of acute coronary syndromes in this questionnaire survey was satisfactory and evidence based. No real differences were found between the management strategies adopted by cardiologists or non-cardiologists. Physicians working in centres with interventional facilities were no more inclined towards using primary PTCA or rescue angioplasty than those working in centres without such facilities.     

How cardiologists learn about echocardiography. A reminder for medical educators and legislators.

Mandatory continuing medical education, because of the need to validate participation, rewards classroom activities but not self-education. To determine if self-education is still a major study method for practicing physicians, we surveyed 158 cardiologists to learn how they first heard of, and continued their education in, echocardiography, a technique in which 81% of the physician-sample receiving no training in medical school, residency, or fellowship. Initial and continuing sources of information included professional journals and literature, meetings and conferences, discussion with colleagues, and courses. Professional journals ranked first in use; individual and group learning activities were used about equally by physicians. Recent legislation requiring validation of attendance may cause educators and legislators to ignore the self-learner. This study should remind educators and legislators that variations in learning style must be considered when planning and legislating approaches in continuing medical education.     

Prozessorientierte und standardisierte Umsetzung von DGK-Leitlinien

The guidelines of the German Cardiac Society (DGK) are aimed at achieving nationwide, uniform quality standards in cardiology. In addition to their medical and quality assurance aspects, the guidelines are also helpful in certification processes and as a normative standard in legal and health care policy questions. However, the implementation of DGK guidelines in clinical practice depends on local and regional structures, which can lead to significant differences between the various hospitals. This makes standardised quality management difficult and reduces the use of the DGK guidelines as a standardised tool in clinical, legal and health-policy issues. In addition, the figures relating to the health-care reality cannot be inferred from the available documentation system, but need to be generated by means of additional registers. Finally, the guidelines are not detailed enough for clinico-practical work in individual cases, since naturally alternative treatment procedures for which there is good supporting evidence must also be represented. IT-supported standardised process modelling of the guidelines can help in their practical implementation and offers cardiologists a possible basis for a process-oriented perspective including quality management, a tool for certification processes and optimised process documentation. Individual and flexible organisation possibilities offer the opportunity to tailor optionally available procedures derived from the obligatory DGK guideline procedures on prevention, diagnosis, therapy or rehabilitation. The implementation of these principles is put into concrete terms on the basis of ST elevation myocardial infarction (STEMI) guidelines.     

The impact of statistical adjustment on economic profiles of interventional cardiologists.

OBJECTIVES: The objective of this study was to identify preprocedure patient factors associated with percutaneous intervention costs and to examine the impact of these patient factors on economic profiles of interventional cardiologists. BACKGROUND: There is increasing demand for information about comparative resource use patterns of interventional cardiologists. Economic provider profiles, however, often fail to account for patient characteristics. METHODS: Data were obtained from Duke Medical Center cost and clinical information systems for 1,949 procedures performed by 13 providers between July 1, 1997, and December 31, 1998. Patient factors that influenced cost were identified using multiple regression analysis. After assessing interprovider variation in unadjusted cost, mixed linear models were used to examine how much cost variability was associated with the provider when patient characteristics were taken into account. RESULTS: Total hospital costs averaged $15,643 (median, $13,809), $6,515 of which represented catheterization laboratory costs. Disease severity, acuity, comorbid illness and lesion type influenced total costs (R(2) = 38%), whereas catheterization costs were affected by lesion type and acuity (R(2) = 32%). Patient characteristics varied significantly among providers. Unadjusted total costs were weakly associated with provider, and this association disappeared after accounting for patient factors. The provider influence on catheterization costs persisted after adjusting for patient characteristics. Furthermore, the pattern of variation changed: the adjusted analysis identified three new outliers, and two providers lost their outlier status. Only one provider was consistently identified as an outlier in the unadjusted and adjusted analyses. CONCLUSIONS: Economic profiles of interventional cardiologists may be misleading if they do not adequately adjust for patient characteristics before procedure.     

A summary of recommendations for occupational radiation protection in interventional cardiology

The radiation dose received by cardiologists during percutaneous coronary interventions, electrophysiology procedures, and other interventional cardiology procedures can vary by more than an order of magnitude for the same type of procedure and for similar patient doses. There is particular concern regarding occupational dose to the lens of the eye. This document provides recommendations for occupational radiation protection for physicians and other staff in the interventional suite. Simple methods for reducing or minimizing occupational radiation dose include minimizing fluoroscopy time and the number of acquired images; using available patient dose reduction technologies; using good imaging‐chain geometry; collimating; avoiding high‐scatter areas; using protective shielding; using imaging equipment whose performance is controlled through a quality assurance program; and wearing personal dosimeters so that you know your dose. Effective use of these methods requires both appropriate education and training in radiation protection for all interventional cardiology personnel, and the availability of appropriate protective tools and equipment. Regular review and investigation of personnel monitoring results, accompanied as appropriate by changes in how procedures are performed and equipment used, will ensure continual improvement in the practice of radiation protection in the interventional suite. These recommendations for occupational radiation protection in interventional cardiology and electrophysiology have been endorsed by the Asian Pacific Society of Interventional Cardiology, the European Association of Percutaneous Cardiovascular Interventions, the Latin American Society of Interventional Cardiology, and the Society for Cardiovascular Angiography and Interventions. © 2012 Wiley Periodicals, Inc.     

Who is a cardiologist: Usurpers spawn?

Cerebrovascular disease is the number one killer worldwide. It is increasing in epidemic proportion in developing countries as well, including India. Trained cardiologists are few and scattered in urban areas and there exists a huge shortage of personnel in clinical arena of cardiology specialty. The problem is manifest not only in diagnostics but also in treatment. This space is appropriated by a large number of clinical professionals posing as true cardiologists. Thus, currently there is a critical need to define who can be called a cardiologist and who can be accorded the privilege to treat and even perform interventional procedures. Further, the only credible way to fill this gap is to increase the infrastructure, the staff and the number of teaching, academic hospitals so that there could be an increase in the number of trained cardiologists. Alternate approach to dilute the educational, skill, and experience requirements of the physicians so that more can qualify to be called as cardiologists is likely to be counter-productive since this approach will lead to dilution in the quality of cardiologists which will consequently lead to dilution in the quality of health-care delivery. Further, the irony of matter is that while the pool of cardiologist is increased with the plea of serving rural areas, the hard reality is that very few if any of these so-called trained physicians ever serve the rural area. Thus, it is in this context the tendency to follow the second course should be firmly resisted as also the need to define “who is a cardiologist.”     

Heart failure treatment in Portuguese hospitals: results of a survey.

The management of heart failure in Europe is largely conducted by primary care physicians in out-patient clinics and by cardiologists and internists in hospitals. Several reports suggest differences among these specialists regarding knowledge and actual practice, and indicate that the application of guidelines is far from optimal. In order to look for differences between cardiologists and internists in terms of implementation of guidelines a survey was carried out among the directors of 83 hospital departments of cardiology and internal medicine in Portugal. The survey included questions about diagnostic and treatment protocols, special areas for management, and suggestions to improve the quality of heart failure patient treatment. The answers suggest that in Portuguese hospitals at least half of the patients with HF are treated by internists. Treatment protocols exist in about 25% of the cardiology departments but are virtually non-existent in internal medicine. The use and availability of echocardiography are high in cardiology but no more than reasonable in internal medicine. There are neither special in-hospital areas nor specialized nurses for the treatment of HF. Cardiologists recognize the need for greater specialization in this field--doctors, nurses and clinics--but this is not a priority for internists. An effort should be made to improve in-hospital HF treatment.     

Recommendations for occupational radiation protection in interventional cardiology

The radiation dose received by cardiologists during percutaneous coronary interventions, electrophysiology procedures and other interventional cardiology procedures can vary by more than an order of magnitude for the same type of procedure and for similar patient doses. There is particular concern regarding occupational dose to the lens of the eye. This document provides recommendations for occupational radiation protection for physicians and other staff in the interventional suite. Simple methods for reducing or minimizing occupational radiation dose include: minimizing fluoroscopy time and the number of acquired images; using available patient dose reduction technologies; using good imaging‐chain geometry; collimating; avoiding high‐scatter areas; using protective shielding; using imaging equipment whose performance is controlled through a quality assurance programme; and wearing personal dosimeters so that you know your dose. Effective use of these methods requires both appropriate education and training in radiation protection for all interventional cardiology personnel, and the availability of appropriate protective tools and equipment. Regular review and investigation of personnel monitoring results, accompanied as appropriate by changes in how procedures are performed and equipment used, will ensure continual improvement in the practice of radiation protection in the interventional suite. These recommendations for occupational radiation protection in interventional cardiology and electrophysiology have been endorsed by the Asian Pacific Society of Interventional Cardiology, the European Association of Percutaneous Cardiovascular Interventions, the Latin American Society of Interventional Cardiology, and the Society for Cardiovascular Angiography and Interventions.© 2013 Wiley Periodicals, Inc.     

Optimizing Survival from Out‐of‐Hospital Cardiac Arrest

Survival From Out‐of‐Hospital Cardiac Arrest. Cardiac arrest is an important public health problem and often occurs in the out‐of‐hospital setting in patients without a prior history of heart disease. Very few communities or emergency medical service (EMS) systems report survival rates for out‐of‐hospital cardiac arrest. Among those who do, survival rates vary substantially between cities, due in large part to community differences in the chain of survival. To improve survival in cardiac arrest, care must be optimized at each point along the cardiac arrest continuum, including a rapid emergency response, provision of cardiopulmonary resuscitation (CPR) by bystanders, delivery of high‐quality chest compressions with minimal interruptions by first responders, rapid defibrillation, and optimization of postresuscitation care, including therapeutic hypothermia. Important current initiatives to improve cardiac arrest survival include hands‐only CPR delivered by laypersons prior to the arrival of EMS, dispatcher‐assisted CPR, and implementation of hospital‐based therapeutic hypothermia protocols to improve postresuscitation care. Optimizing cardiac arrest survival requires a team effort between EMS directors, emergency physicians, cardiologists, hospital leadership, and the public. (J Cardiovasc Electrophysiol, Vol. 21, pp. 590‐595, May 2010)     

Quality assurance in the emergency department: evaluation of the ECG review process.

STUDY OBJECTIVE: To determine whether the review of emergency department ECGs by cardiologists contributes to the quality of patient care. STUDY DESIGN: We retrospectively analyzed ED ECGs and compared interpretations of the treating emergency physicians with those of the reviewing cardiologists. We then evaluated the ED care of patients with potentially significant ECG abnormalities that were not detected by the treating emergency physicians, as well as the care of patients whose ECGs were "flagged" by the reviewing cardiologists as needing follow-up. SETTING: University hospital. PARTICIPANTS: Four hundred consecutive ECGs obtained on ED patients. MEASUREMENTS AND MAIN RESULTS: Thirty-three of the 400 tracings had undetected potentially significant or critical ECG abnormalities; this adversely affected patient care in two cases. These two tracings were not flagged by the reviewing cardiologists. Thirteen ECGs were flagged by the cardiologists; patient care was not altered in any of these cases. CONCLUSION: Review of ED ECGs by cardiologists did not affect patient care at our institution.     

Quality of care: do we care?

The quality of U.S. health care must improve. Practicing physicians need to become involved in generating new knowledge about what does and does not work in medical practice. Physicians might, for example, participate in building national databases on chronic and acute conditions using data from their patients or might help to enroll patients in cohort studies or experimental trials. Furthermore, our knowledge is now sufficient to support a substantial investment of funds in improving what physicians now do in medical practice and in developing publicly available standards of medical practice. Such standards or guidelines could be used by both physicians and patients as part of an explicit process to assess the medical appropriateness of expensive or dangerous procedures before they are done. In addition, the competence with which care is delivered also needs to be measured. Both of these assessments should be used prospectively by physicians to help patients choose the referral source that will maximize their preferences.