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CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

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March 26th, 2012

ACC.12 Roundup

CardioExchange has been dedicated to bringing you the latest from ACC 2012, and even though the meeting has ended, the buzz has just begun! Check out our coverage below ─ and some of the great debates these posts have sparked ─ then tell us what you think!

Previews:

News:

Analysis:

Follow the Fellows:

 

An Inspiring Run

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March 26th, 2012

Meet the New Boss, Same as the Old Boss — The Affordable Care Act and Medical Liability

Several Cardiology Fellows who are attending ACC.12 this week are blogging together on CardioExchange.  The Fellows include Tariq Ahmad, Bill Cornwell, Megan Coylewright, Jeremiah Depta, and John Ryan (moderator). Read the previous post here. Read the next one here.

Since its passage in 2010, the Affordable Care Act (aka Obamacare) has been a lightning rod for controversy. This week, the battle reaches the Supreme Court, as the Justices begin hearing arguments on the constitutionality of the individual mandate. For a great discussion of this topic, go here. The Court has taken the highly unusual step of allowing oral arguments to progress for several days, due to the complexity and significance of the issues. This case may be a historic one, and the audio recordings of the oral arguments can be heard here.

Although the legal status of the Act remains uncertain, whether it survives or falls will have little impact on one aspect of physician life: medical liability. The Act’s minimal impact on the current malpractice landscape was a key element of a fascinating presentation today, U.S. Health Reform: What’s Missing?  We were fortunate to hear from Dr. Richard Anderson, chairman of The Doctors Company, the largest physician-owned liability insurance provider in the nation.  The ACC has recently endorsed The Doctors Company, and Dr. Anderson was here to provide his unique insights into a problem that all cardiologists encounter in one way or another.

Congress never misses an opportunity to miss an opportunity, and the Affordable Care Act is no exception, at least with regards to malpractice reform. In fact, as pointed out in today’s presentation, the Act actually makes certain changes more difficult.  Section 10607, which authorizes demonstration projects to explore changes to the current liability system, prohibits changes which cap non-economic damages or limit lawyers’ fees. However, despite these limitations, these demonstration projects are moving forward; for a great summary, see this essay.

So for the time being at least, change will not be happening at the federal level.  Furthermore, as discussed in today’s presentation, the changing nature of medical practice will likely increase liability exposure. With the passage of the Act, millions more patients will enter the medical system. If lawsuit rates remain unchanged, a raft of lawsuits will come with them. Second, the increased turnovers and increased number of physician extenders needed in medical practice today may result in increased errors, and more litigation. Finally, the emphasis on cost control, if not tied to liability protection, may trap providers between an irresistible force and an immovable object. As tests and procedures that don’t make economic sense are gradually pushed aside, failure to order these tests should not expose physicians to liability.   Without these protections, efforts at cost control will likely never reach their goal.

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March 26th, 2012

Selections from Richard Lehman’s Literature Review: Week of March 26th

CardioExchange is pleased to reprint selections from Dr. Richard Lehman’s weekly journal review blog at BMJ.com. Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog.

Week of March 26th

JAMA  21 Mar 2012  Vol 307

Epinephrine in ED Response to Cardiac Arrest (pg. 1161): When in Japan, do not attempt to drop down dead. In 800 fire stations around the Islands of the Sun, teams of emergency medical service personnel stand ready to rush out and perform resuscitation for out-of-hospital cardiac arrest, which cannot be discontinued until an ambulance arrives and you are taken to hospital, barely alive or truly dead. This non-randomized study of Japanese CPR shows that if the emergency team used epinephrine (adrenalin), your chance of having spontaneous circulation when you arrived in hospital would be 18.5%, and if they did not, it would be 5.7%. On the other hand, your chance of being alive at one month without major neurological impairment would be 1.4% if you had been given epinephrine, and 2.2% if you had not. So I think we can conclude that epinephrine should not be given during CPR. Next we need to find out whether out-of-hospital CPR should be given at all, since there is no firm evidence one way or the other.

NEJM  22 Mar 2012  Vol 366

A Thrombolytic Twice as Effective as Alteplase? (pg. 1099): The first trials of thrombolysis for stroke were carried out twenty years ago, but treatment with alteplase still occupies a marginal place in the everyday management of acute ischaemic stroke, despite efforts to encourage its use within the small window of benefit. But what if there were a thrombolytic agent that was nearly twice as good? This publicly funded Antipodean study compared two doses of tenecteplase with a standard dose of alteplase with just 25 carefully selected patients in each group. The higher dose of tenecteplase definitely produced the best results (72% v 40% disability-free at 90 days), but we need a bigger trial.

Phase I Study of Monoclonal Antibodies for Reducing LDL-C (pg. 1108): When monoclonal antibodies were first produced, nearly 40 years ago, we were told to expect lots of magic bullets for a wide array of hitherto untreatable diseases. My whole working lifetime has passed by in those decades, and only a handful of my patients ever received treatment with a monoclonal antibody, usually with broad and unpredictable effects. High low-density lipoprotein cholesterol is a common biochemical finding, whether due to heritable causes or not. It is certainly associated with worse cardiovascular outcomes. So what might happen if we give people with raised LDL-C a monoclonal antibody to the enzyme which promotes LDL-C production? This enzyme is called proprotein convertase subtilisin/kexin 9 [PCSK9], but I don’t expect you to remember that. And the monoclonal antibody to PCSK9 is designated as REGN727/SAR236553 (REGN727), and I don’t expect you to remember that either. In fact I don’t expect you to remember anything about this study at all, except that the stuff reduced LDL-C levels in a few healthy volunteers and a few subjects with familial and non-familial hypercholesterolaemia, and did them no immediate harm. Or good. Now just keep this in the back of your mind, for the ten years of phase 2 and 3 trials that it will need to see if it’s safe and if it reduces events.

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March 26th, 2012

PARTNER: TAVR Results Appear Durable at 2 Years

Two-year results of the influential PARTNER trial provide continued support for the growing acceptance of transcatheter aortic valve replacement (TAVR) in clinical practice. Previously, results of PARTNER at 1 year had demonstrated similar mortality in high-risk patients with aortic stenosis who underwent TAVR or surgery. Now, the 2-year results have been presented at the American College of Cardiology and published simultaneously in the New England Journal of Medicine.

Two-year mortality:

  • ITT analysis: 33.9% in the TAVR group and 35.0% in the AVR group (HR 0.90, CI 0.71-1.15, p=0.41)
  • As-treated analysis: 33.9% and 32.7% (HR 0.98, CI 0.76-1.25, p=0.85)

Stroke at 2 years:

  • ITT: 7.7% and 4.9% (HR 1.22, CI 0.67-2.23, p=0.52)

All-cause mortality or stroke at 2 years:

  • ITT: 37.1% and 36.4% (HR 0.93, CI 0.73-1.18, p=0.55)

The PARTNER investigators reported that the valve gradients and areas were similar between TAVR and AVR at 2 years and that they had found no evidence of structural valve deterioration. However, periprocedural aortic regurgitation was a highly significant predictor of late mortality (p<0.001).

“We’re most concerned about valve durability, which you have to look at over five to 10 years, but any longer-term information is useful because trends tend to hold true over time,” said Susheel Kodali, who presented the results, in an ACC press release. “We have no evidence that the initial good results in improved valve performance have deteriorated during the follow-up to this time point. TAVR appears to be as durable as AVR.

“During this follow-up, we observed that significant leakiness around the valve was associated with higher subsequent mortality in TAVR patients, but it’s important to note that overall mortality between the two groups is the same,” he said. “Now we have a target – we know what to fix in the future. TAVR is already comparable to results for AVR in the most experienced surgeons’ hands. If we can reduce these leaks, there’s a good chance we can reduce mortality with TAVR even more.”

The PARTNER investigators concluded that the study “supports the use of TAVR as an alternative to surgery in selected high-risk patients with aortic stenosis.”

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March 26th, 2012

CT Angiography to Rule Out CAD in Chest-Pain Patients

Each year, 6 million people in the U.S. arrive at the emergency department (ED) with acute chest pain. Although only 10% to 15% of them turn out to have an acute coronary syndrome (ACS), most are admitted to the hospital. Coronary CT angiography (CCTA) has been proposed as a good method to quickly establish the presence or absence of coronary disease and to allow many of these patients to return home sooner.

In a presentation at the ACC and in a simultaneous publication in the New England Journal of Medicine, the ACRIN (American College of Radiology Imaging Network) investigators report the findings of ACRIN PA 4005, the largest trial to date of the strategy to use CCTA to allow for more-rapid ruling out of coronary disease in patients with possible acute coronary syndrome. Investigators randomized 1370 patients with chest pain, in a 2:1 ratio, to either CCTA or conventional care.

The primary outcome was the safety at 30 days of patients with a negative CCTA. Among the 640 patients who had a negative CCTA examination, there were no MIs or cardiac deaths within 30 days.

The investigators also observed that, compared with controls, patients in the CCTA group were more likely to be discharged from the emergency department (49.6% vs. 22.7%) and had a shorter median length of stay (18.0 hours vs. 24.8 hours). Coronary disease was also more likely to be detected in the CCTA group (9.0% versus 3.5%). Utilization of healthcare resources was similar in both groups.

The major drawback to CCTA is radiation, but ACRIN investigator Harold Litt pointed out that the radiation dose received by patients for CCTA is now lower than the dose received during nuclear imaging studies. “We believe that a CCTA-based strategy can safely and efficiently redirect many patients home who would otherwise be admitted,” the authors concluded.

Categories: Cardiac Imaging
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March 25th, 2012

Academics vs. Private Practice

Several Cardiology Fellows who are attending ACC.12 this week are blogging together on CardioExchange.  The Fellows include Tariq Ahmad, Bill Cornwell, Megan Coylewright, Jeremiah Depta, and John Ryan (moderator). Read the previous post here. Read the next one here.

One decision all fellows-in-training (FIT) will face is whether to pursue a career in academics or in private practice. At the first of many FIT sessions, a panel very effectively reviewed the pros and cons of the two options. The overarching theme seemed to be that there are unavoidable stressors regardless of a chosen career path.

Let’s take private practice as an example: you have to deal with the job market. Some interesting statistics regarding jobs for new graduates: in 2005, there were 2,500 jobs available for the ~800 graduates of US cardiology fellowships; the “stenting revolution” was well underway and the ICD implantation was on the rise. In short, it was a great time to enter the job market. Now in 2012, we have seen changes in CMS rules and policies, reductions in reimbursement rates for services rendered, and an overall “cooling” of the job market.  Are jobs out there? Of course they are, but there are no guarantees that the dream-job is yours for the taking, as it might have been a few years ago. Compromises include less than ideal locations and lower salaries.  And who will be your employer? In private practice, it seems there are three options: a hospital, an independently owned group, or yourself.  In the hospital-owned cardiology groups, cardiologists are protected from many business and policy-making decisions, such as changes in reimbursements (they are salaried employees), hiring of staff, equipment selection and EP/cath lab operations.  However, this necessarily implies that cardiologists are sacrificing a great deal of autonomy. So, while a hospital-owned model may spare cardiologists from many anxieties, there is certainly the potential for a whole new set of stressors brought on by a lack of control.

The panelists offered some great advice to help in the decision-making process.  Firstly, it is important to define your career goals – what do you want to achieve in the next five years, and what do you hope to accomplish in the next thirty years? What are you good at? What are you not good at?

It seems obvious should all consider these questions when starting our careers, and yet the panelists emphasized that new graduates really are not taking sufficient time to consider these questions and weigh options accordingly. Throughout our medical training, our goals were always defined for us: in medical school and residency our paths were already paved. In fellowship, we now have the opportunity, for the first time, to define what our goals are and to begin a process that will shape our careers. With this in mind, the decision about academics vs. private practice should not focus as much on matters like reimbursement and autonomy.  Throughout our careers, the market is-certain to change time and time again; fulfillment will only come by focusing on accomplishing short and long term goals, and doing what you are passionate about.

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March 25th, 2012

Why Being at ACC in Person Matters

Several Cardiology Fellows who are attending ACC.12 this week are blogging together on CardioExchange.  The Fellows include Tariq Ahmad, Bill Cornwell, Megan Coylewright, Jeremiah Depta, and John Ryan (moderator). Read the previous post here. Read the next one here.

An educational event on aortic stenosis with astounding teachers (O’Gara, Carabello, Mack, Tuczu, among others) last night proved yet again how essential it is to attend the meetings in person. A brief conversation leads to partnerships, and as John Rumsfeld explained at the Fellows’ Mix and Mingle, it was at ACC conferences as a fellow and young faculty where he met his early mentors and started projects which kicked off his career (now on the ACC Board of Trustees). We are lucky to have the time and resources to attend!

It underscores the need for programs continue to support, encourage, and guide fellows in attending these meetings.

On the topic of active encouragement…my program director, Paul Sorajja, motivated many of us to run in the Shamrock Shuffle today! And there’s a 5K coming up as well.

Hope to see you all at the fellows’ clinical decision making session starting at 4:30 pm…once again, another chance to learn from the great teachers (Brush, Holmes, Nish, O’Gara).

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March 25th, 2012

Face to Face with the Living Legends

Several Cardiology Fellows who are attending ACC.12 this week are blogging together on CardioExchange.  The Fellows include Tariq Ahmad, Bill Cornwell, Megan Coylewright, Jeremiah Depta, and John Ryan (moderator). Read the previous post here. Read the next post here.

Most professional groups have a group of “living legends”: people who have revolutionized the way they practice their job. For guitarists, it is  Eric Clapton; for computer scientists, it is Bill Gates; for basketball players, it is Michael Jordan.

Most people do no get to meet their idols. Today, at ACC 2012, during a session organized by a group of fellows from across the world, trainees in cardiology were able to have face-to-face time with some of cardiology’s living legends. We had read their papers, we had watched them be interviewed: for one of the first times at a national meeting, we were able to meet them and speak to them in person.

I sat beside Dr. Valentine Fuster, from Mount Sinai, who listened intently to my career goals, and offered sage advice. I discussed the state of heart failure research with Dr. Clyde Yancy and listened to what skills Dr. Lynn Stevenson felt are key to becoming a well trained cardiologist. Dr. Tom Bashore and I talked about the future of cardiology training programs, as well as his thoughts about the Ohio State-Syracuse game tonight (he is a big Ohio State fan). Drs. Richard Becker and Samuel Goldhaber spoke with me about my research project on studying adverse thrombotic events in LVAD patients.

This event was a tremendous success. I could tell from turnout as well as from my conversations with other fellows that this session has likely earned a spot in all future meetings.

I do not think that I will even forget the impact of the personal interactions I had today. It was a talk I heard by Dr. Fuster in medical school that attracted me towards internal medicine, witnessing Dr. Patrick O’Gara’s clinical skills made me chose cardiology as a sub-specialty, and inspiration from Dr. Stevenson’s example attracted me towards heart failure. Today, I had the honor to sitting across from them in an informal manner, something I could never do online or by reading a paper.

As the sounds of Michigan Ave. die down, I am busy at work planning the next day’s itinerary. The ACC has constructed an excellent online tool that can be used to plan the day’s events.

The only drawback is my inability to attend multiple sessions at the same time.

Decision, decisions…

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March 25th, 2012

Is it Impossible to Break into Clinical Research? Debunking a Common Misperception

Several Cardiology Fellows who are attending ACC.12 this week are blogging together on CardioExchange.  The Fellows include Tariq Ahmad, Bill Cornwell, Megan Coylewright, Jeremiah Depta, and John Ryan (moderator). Read the previous post here. Read the next one here.

The ACC meeting can be intimidating for fellows.  With a plethora of scientific and educational sessions, trainees often feel lost and sometimes may actually get lost at the meeting.  A common misperception I hear from fellows is that only a few people do the groundbreaking research and it is impossible to “break-in” to the inner circle of scientific investigation. With the constraints of clinical training and limited access to databases, many fellows struggle to get clinical research started and/or finished during their training. Unfortunately, these early experiences with clinical research potentially dissuade people from pursuing a career in clinical investigation.

However, the ACC should inspire fellows and open the avenues available for trainees who want to become clinical investigators.  A gem in the arena of clinical research is the ACC’s National Cardiovascular Data Registry (NCDR). The opportunities to perform clinical research through the NCDR are a perfect way for fellows to launch a clinical research career. I attended a session titled “Getting Access to Data: Successful Examples from the NCDR”.  The session was chaired by Dr. Tracy Wang from DCRI and included Drs. John Rumsfeld (Chief Science Officer for the NCDR), Robert Yeh, Paul Chan, Thomas Maddox, Amy Leigh Miller, and Thomas Tsai. The session involved a panel discussion detailing their experience with NCDR. The panel included many recent graduates who shared with the audience tips on how to propose and complete a project through NCDR.  Many of the panel members were very active clinically and also from procedural fields (i.e. interventional and electrophysiology). It was very encouraging to hear their stories of success, as many of them launched their careers in clinical research through NCDR.

The NCDR now has 7 registries and a website that details the clinical variables included in each registry. Anyone, including fellows, can submit a research proposal. If accepted, the data analysis is funded and performed by DCRI and mentored through representative from NCDR. One of my first clinical research experiences was through the Get With The GuidelinesTM. The process of learning how to ask a novel, focused clinical question, working with a statistician to perform the analysis, and going through the scientific review process leading to publication was invaluable.

The session detailed several important points that I thought might be helpful:

  1. Know the variables collected in each registry and if your clinical question can be answered using those variables.  The variables collected are detailed for each registry on the NCDR website.  An example of the data collected in the ACTION Registry® – GWTG™ is linked here.
  2. Determine if your clinical question is currently being studied or has been published previously through the NCDR.
  3. Identify potential mentors who have published through NCDR on topics similar to your clinical question. The session highlighted how many of the panel members have been mentored by individuals who are not at their home institution. Seeking mentors who have a track record of success in NCDR was strongly encouraged.

A list of NCDR presentations that are being presented at ACC this year are linked here.

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March 25th, 2012

The Pie-ing Game: How Do We Carve up Shrinking Reimbursements?

Several Cardiology Fellows who are attending ACC.12 this week are blogging together on CardioExchange.  The Fellows include Tariq Ahmad, Bill Cornwell, Megan Coylewright, Jeremiah Depta, and John Ryan (moderator). Read the previous post here. Read the next post here.

Everyone knows the reimbursement pie is shrinking, both in terms of the size of the pie, and the piece designated for cardiology. This morning’s session—How to Code and Get Reimbursed—used this metaphor to full effect, and also gave a much needed explanation of how this is happening. Coding and reimbursement is a topic from which many cardiologists remain detached, but all are affected, and should at least know the basics. More importantly, we should all be prepared for what it to come….

The basis of reimbursement, as most know, is an RVU (Relative Value Unit) which is assigned to various procedures and clinical interactions. More complicated interactions and procedures obviously receive higher RVUs. However, assigning the numbers of RVUs is only one part of the process of reimbursement, as I learned today. The Centers for Medicare and Medicaid Services (CMS) reimburse for a clinical interaction based on a sum of three elements:

  1. RVU’s assigned to the procedure itself,
  2. Expense (either direct or indirect) the doctor incurs to perform the procedure and
  3. Cost of the liability coverage associated with the procedure.

Obviously they have complicated formulas to decide the final two elements; providers don’t get to just send the government a bill! Once they have added these three elements, they get a total RVU value which is then multiplied by a conversion factor (determined by law). This final number represents the dollar amount sent back to the provider as reimbursement. In 2000, the conversion factor was 36.62. This year, it was scheduled to drop to 24.67 , but Congress intervened to pass “Doc Fix”, bringing the number back up to 34.04.

So why are reimbursements down? First, the number of RVUs assigned to a particular procedure have decreased because of mandatory bundling of procedures. For example, a nuclear scan that could previously be coded into multiple sections (EF, wall motion, etc) is now coded as a single procedure. Second, the compensation for expenses (cost to maintain echo equipment, nuclear camera, etc) has dropped drastically. Cardiologists used to receive very high compensation for indirect expenses, but not anymore. Finally, the RVU conversion factor has stayed flat or even dropped.

So what is on the horizon? According to the ACC Coding and Reimbursement Working Group, much of the worst is over. With the exception of PCI and procedures like EKGs and CXR, much of the mandatory bundling of cardiovascular procedures has already taken its course. However, there is a nationwide push to increase reimbursement for primary care providers, which will likely come at the expense of specialists. The pie will not be increasing anytime soon.

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