New Medical Overuse Report Emphasizes Importance of Informed Consent, Heart Team
Approach focuses on improving patient care through physician collaboration, patient education
Chicago – The Society of Thoracic Surgeons (STS) recognizes and supports “Proceedings from the National Summit on Overuse,” released today by the American Medical Association and The Joint Commission. This National Summit, held in September 2012, yielded an important, patient-centered analysis of several potentially overused medical procedures, including percutaneous coronary intervention (PCI) for patients with heart disease.
Although PCI is attractive since it is less invasive than heart surgery, this report challenges the appropriateness of PCI performed in some patients with stable ischemic heart disease (SIHD) who might be better served with other therapies, such as medications or surgery (coronary artery bypass grafting). In particular, the report recognizes PCI overuse as an important issue for patients who are at risk for premature mortality due to severe, extensive coronary artery disease.
PCI, which involves the insertion of metal stents into narrowed or blocked coronary arteries, is one of multiple therapies available to manage patients with ischemic heart disease. Although PCI can open a narrowed artery, some patients with minimal disease, minor symptoms, or an inadequate trial of medications may be best treated by medications alone rather than PCI or surgery.
According to the report, approximately 160,000 elective (non-emergency) PCI procedures were performed on Medicare recipients in 2011. Accreditation for Cardiovascular Excellence (ACE) data estimate that 8% of PCI procedures were inappropriate. An analysis of the American College of Cardiology’s National Cardiovascular Data Registry classified 50% of elective PCIs as appropriate, 38% as uncertain, and 12% as inappropriate. In patients who may not need PCI, the consequence of the procedure is predominantly economic, i.e., the financial burden of a procedure that may have been avoided. However, many studies have provided scientific evidence of improved long-term survival with surgery (see graph), and these patients lose that opportunity of benefit if only PCI is offered.
CABG Surgery for the Treatment of Coronary Artery Disease
STS applauds the National Summit report for its effort to identify which patients are best served with PCI, as opposed to other therapies such as medications alone or coronary artery bypass graft (CABG) surgery. Cardiothoracic surgeons perform CABG surgery by grafting a blood vessel from the aorta to the coronary artery, bypassing the blocked section of the coronary artery. The procedure has been greatly improved over the past 50 years and has been performed on millions of patients worldwide. CABG surgery’s safety, durability, and benefits – in terms of both survival and quality of life - have been thoroughly demonstrated through clinical research.
“STS has concerns that many patients and physicians are not aware of the distinct advantages provided by coronary bypass surgery,” said Peter K. Smith, MD, STS representative on the Overuse Panel and Division Chief of Cardiovascular and Thoracic Surgery at Duke University. “Though more invasive than PCI, CABG surgery remains the best therapy for the vast majority of patients with left main disease, multivessel coronary artery disease, and other patients who have failed medical or interventional therapy. “
Cardiologists and cardiac surgeons continue to strive to determine the optimal therapy for each patient. For example, a collaborative trial including cardiologists and cardiothoracic surgeons published in The New England Journal of Medicine in 2012 showed a survival advantage for CABG over PCI in treating multivessel coronary artery disease in patients with diabetes. Diabetics comprise one third of all patients with ischemic heart disease in the U.S.
Informed Consent and the Heart Team Approach Critical to Patient Safety
“We support the work of the Summit and the proposals for elective PCI included in these proceedings, particularly the need for informed consent and understanding of the risks and benefits associated with CABG, PCI, and continued or enhanced medical therapy alone,” said Douglas E. Wood, MD, STS President. “We appreciate the opportunity to participate in the Summit with our cardiology colleagues and others. STS advocates for the heart team approach to decision making and encourages input from cardiologists, primary care practitioners, surgeons, and—most importantly—patients, to help ensure that every patient receives the highest quality care.”
The Proceedings identify several aspects of the informed consent process that could be improved by further defining the heart team and its interactions, as well as specific details to be included in an individualized consent form. “We need to reach consensus on a process where the patient is the most important part of the decision-making process and is accurately informed of the full range of options in understandable terms,” said Dr. Smith. “Establishing this consensus for elective PCI may be the most important outcome of the Summit, and may have implications for other forms of therapy.”
STS has long been a leading proponent of patient-centered and evidence-based health care, as well as a pioneer in associated quality initiatives. This philosophy is exemplified by the Society’s participation in the Choosing Wisely® campaign, led by the American Board of Internal Medicine Foundation. Choosing Wisely promotes the formulation and dissemination of evidence-based recommendations to help physicians and patients engage in conversations aimed at addressing the overuse of tests and procedures, supporting physician efforts to help patients make wise choices about their health care.
Public Reporting and Public Education Necessary
The Summit Proceedings address standardized reporting initiatives and public education, of which STS also has been a leading proponent for more than 20 years. The STS National Database, established in 1989, is the largest cardiothoracic surgery outcomes and quality improvement program in the world. The Adult Cardiac Surgery component of the STS National Database contains more than 5 million cardiac surgery procedure records and has more than 3,000 participating surgeons. Participants in the database receive regular outcomes reports that allow comparison of local outcomes to national and regional benchmarks. Participants also have the opportunity to publicly report their outcomes on the STS website and/or the Consumer Reports website.
To schedule an interview with an STS representative, contact Cassie Brasseur at 312-202-5865 or cbrasseur [at] sts [dot] org.
Founded in 1964, The Society of Thoracic Surgeons is a not-for-profit organization representing more than 6,600 cardiothoracic surgeons, researchers, and allied health care professionals worldwide who are dedicated to ensuring the best possible outcomes for surgeries of the heart, lung, and esophagus, as well as other surgical procedures within the chest. The Society’s mission is to enhance the ability of cardiothoracic surgeons to provide the highest quality patient care through education, research, and advocacy.
Graph submitted by The Society of Thoracic Surgeons to the National Summit on Overuse.