Cardiology and the quality of medical practice

Article Abstract:

The cost of medical care is rising rapidly, and there is concern that the benefits conferred by numerous high technology procedures are not commensurate with either the costs or the risks. Any attempt at cost containment must begin with an evaluation of the meaning of high quality care. Cardiology dominates the medical scene more and more as the life styles in the industrialized world, coupled with an aging population, make heart and blood vessel diseases a major problem. Medical and surgical techniques for patients with cardiovascular disease are costly, and many of these procedures are performed without knowledge of their true effectiveness. In one study, 23 percent of pacemaker implants were deemed unnecessary, and another 13 percent were questionable. In three other trials, percutaneous transluminal coronary angioplasty (PTCA, insertion of a catheter to widen a narrowed artery) immediately after anticlotting drug therapy was not only not useful, it was associated with numerous complications, including emergency coronary artery bypass grafts (CABG) surgery. Three large studies have confirmed that CABG benefits only certain types of patients, and survival was the only measure of benefit. There was no decrease in nonfatal heart attacks. One study found that 56 percent of CABG surgery was appropriate, 30 percent was questionable, and 14 percent was inappropriate. Another study by a British team found 35 percent of CABG operations inappropriate compared with 13 percent judged inappropriate by the US team. To assess the likelihood of inappropriate use, the use of pacemakers, PTCA, and CABG was analyzed by region. A heart patient is twice as likely to undergo PTCA or CABG in the Midwest than in the Northeast, even though there are fewer cardiologists per 100,000 population in the Midwest. The American ideal that every individual should have equal access to all medical technology regardless of cost is inconsistent with cost containment of heath care in a society with a growing population of aged citizens. There is no way to provide increasingly expensive technology to all patients regardless of prognosis and yet contain costs. (Consumer Summary produced by Reliance Medical Information, Inc.)

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The future of adult cardiology

Article Abstract:

The Council on Long Range Planning and Development of the American Medical Association has examined the future environmental trends which will uniquely affect the development of the practice of adult cardiology. Nearly 46 percent of the 2.1 million deaths that occurred in 1986 within the United States were related to diseases which affected either the heart or the vascular system. Of these deaths, 79 percent occurred because of heart disease, while the remaining deaths occurred because of stroke, hardening of the arteries (atherosclerosis), elevated blood pressure (hypertension) and miscellaneous causes. There have been, however, dramatic improvements in the annual number of deaths caused by cardiovascular diseases. Changes in lifestyle (e.g., better diet) and medical advances in the prevention and treatment of cardiovascular disease are seen as being important in this reduction. At this time, there are 14,200 self-designated cardiologists practicing in the United States. Approximately 85 percent of these physicians are board certified in cardiovascular diseases. The specialty itself has changed from one of diagnosis to one involved in direct, often invasive diagnostic procedures and surgical repair. In 1986, 84 percent of all cardiologists were involved with direct patient care, of which 90 are involved in office-based practices. The services provided have been increasing at a very rapid rate. For example, the number of cardiac catheterizations doubled between 1981 and 1986 (when there were 775,000 cases). In 1986, the average compensation for a practicing cardiologist was $162,000 (after professional expenses, before taxes), an increase of 29 percent since 1983. By comparison, the income of a physician in general practice rose during the same period by only 15 percent to $119,500. There is a continuing trend for a rapid increase in the number of cardiologists, which may lead to increased competition among them. New areas of cardiology subdivision which include the use of visualization by ultrasound devices and cardiac testing are beginning.

Standards, Reports, Demographic aspects, Cardiologists, American Medical Association. Council on Long Range Planning and Development

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Cardiology and the quality of medical practice: a response

Article Abstract:

The article by the Cardiology Working Group in the January 23, 1991 issue of Journal of the American Medical Association explores the issues of escalation of health care costs, especially in the highly technological area of cardiology. The specific issue is appropriate use of technology, or value. Value is a function of outcomes, and outcomes are not well defined across the range of medical options, although there has been a great deal of interest in ''outcome research'' by the federal government, insurance companies and other third-party payers, and the medical community. Cost is more easily identifiable, but not all costs are controllable: the aging population will put more people under Medicare regardless of cost containment measures. And high-cost cardiology will be the major type of care provided. As for the use of high technology, not enough evidence exists to state, as did the Cardiology Working Group, that expensive procedures are often used inappropriately. As clinical definitions change, so too do the indications for pacemakers, coronary artery bypass surgery, and percutaneous transluminal coronary angioplasty (PTCA, in which a catheter is inserted into an artery to enlarge a narrowed area). The increase in bypass surgery may not indicate that it is used inappropriately, but rather that more people require it, and more are returning after several years for a second or third operation. Also, each patient is an individual, and differences in procedures are also a function of a decision made by the patient and the doctor together. Clinical dilemmas must be addressed, guidelines and ''outcomes'' research must provide information, and incentives should ensure efficiency. High technology should provide high quality medical care to more people at a lower cost. (Consumer Summary produced by Reliance Medical Information, Inc.)

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