Recently there have been stories of inappropriate cardiac procedures being. There are at least four glaring examples of instances in which cardiologists have acted in a way that was not consistent with what others would have considered optimal patient care. This behavior diminishes a hospital’s reputation in relation to mission, community need and quality. The cardiologists were found to be doing inappropriate angioplasties or recommending inappropriate surgeries. In some cases the inappropriate care was deemed so egregious that the hospitals where it was performed either closed or had to change management. Why did these occur?
In all occurrences, a single physician or pair of physicians were doing both procedures and the associated “peer review”. Institutional oversight of laboratories was deemed inadequate. The physicians were all high volume users of the hospital facilities and at times were encouraged by the hospital to continue, presumably because of the revenue that these doctors generated. In one instance, a hospital CEO listened to staff concerns regarding inappropriate procedures and asked outside consultants for a review of cases. In other occasions outside review was initiated by the legal system (OIG, or state regulators) and sanctions were brought on the hospitals.
Errors in medical judgment may be related to several factors:
1. Proximity/Availability Bias (this is a procedure that is familiar to me and I do it – it must be good);
2. Financial Bias (this procedure is highly valued because payers pay a lot for it – it must be good for many patients, thus I should do more);
3. Representative Bias/Confirmation Trap (I believe the data that support “my procedure” – the people doing studies that don’t support my procedure aren’t as good as I and they just don’t understand new advances in the procedure);
4. Finally there may be frank dishonesty (I can get paid for this, and I believe that no one is going to argue with my judgment).
Continuous quality review helps expose and overcome these biases.
One might ask why hospital systems didn’t recognize these biases in their physicians and why they didn’t correct them and the associated misuse of hospital facilities. The answers are complex, but often reflect similar biases and some “blinders”. I have been in many hospitals where a service line director says something like, “Dr. xxx is one of our best doctors, he/she does a lot of procedures”. Follow up of this doctor’s long-term patient outcomes and data on appropriateness are usually lacking. While this doctor generates revenue, hospital/system staff members are often afraid of alienating him/her by questioning his practices. If there is review of quality, the review committee is often chaired or run in isolation by this physician/surgeon. Another source of review, especially of adverse outcomes, is the Morbidity and Mortality review. The weakness of M&M review is that it often focuses on one or two cases and frequently ends up with censure, embarrassment or punishment of an operator. Instead these meetings should work to find system errors that can be corrected to prevent future undesirable events. If education and definition of system errors were to be done, then the hospital/system would be fulfilling the Institute of Medicine’s first mandate for quality health care making it SAFE. A third source of review is asking an outside reviewer to go over a sampling of cases. Guidelines for voluntary peer review for cardiac catheterization laboratories have been available since at least 1997
Recently the SCAI and ACC have asked the state of Maryland to mandate better cardiac catheterization lab oversight and review, including an outside body similar to the Accreditation for Cardiovascular Excellence (ACE) program.
Annual or quarterly reviews should be done by several physicians, some of who would not have a direct interest in doing the procedures (at least 1 or 2 non invasive cardiologists). Review should always be done with input from more than one clinical group. Sometimes this may necessitate bringing in an “outsider” who is still in practice, or recently out of practice.
If reviews are undertaken with these objectives in mind, we are likely to “Fix the problem, not the blame”.
This way our systems will provide measurably better care to all.
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