Catheterization and Cardiovascular Diagnosis 37:131 (1 996)

Editorial Comment

Can We Defend the Bill of Rights?

Joel K. Kahn, MD William Beaumont Hospital Royal Oak, Michigan

Malone and coworkers present interesting retrospective data on patterns of utilization of right heart catheterization during coronary angiograph ;y in two community hospitals in Milwaukee during two months of 1993 [l]. They found that for individual operators, the rates of utilization varied from 10% to 90% of cases. The wide variations were not accounted for by differences in patient char- acteristics although patients with cardiomyopathy, congestive heart failurn:, valvular heart disease, and advanced age were more likely to have a right heart catheterization. Extrapolating to all of the United States, the authors estimated that up to $130 million in professional fees for right heart catheterization need explanation. Can we defend the bill of right heart catheterizations?

As a cardiology community, we will be asked to explain the wide variation in the utilization of routine right heart catheteriza- tions during diagnostic coronary arteriography. There are at least three reasoix that come to mind. The first explanation is that the operators performing frequent right heart catheterizations believe that the yield of additional hemodynamic information outweighs the additional time, resources, and procedural risks. On an emo- tional level, it may be reasonable to argue that if one is already taking the time and accepting the liability of putting a patient through an invasive procedure that is anticipated to be the defin- itive cardiovascular examination relating to issues of diagnosis, treatment, and prognosis, then the maximal amount of information should be obtained. When one considers that a screening satura- tion run and right heart chamber pressure measurements may add only 5-10 minutes to the procedure in skilled hands, it can be argued that even a 5-15% yield of information that might affect diagnosis or patient care is justifiable and even necessary [2]. At William Beaumont Hospital this judgment is made by individual operators and is not subject to peer review.

A second explanation for the wide variability in rates of right heart catheterizations relates to habits and definitions of “routine” that develop during cardiovascular fellowship training. During my three-year general cardiology fellowship at the University of Texas

Southwestern Medical Center in Dallas, all coronary arterio- graphic procedures were routinely performed with right heart cath- eterization. This habit reflected the large number of research pro- tocol patients who were studied and the desire to train fellows in all aspects of catheterization skills. Many other university-based training programs have a similar format. Therefore I developed a habit, as did many other fellows training in programs like mine, to view a routine diagnostic catheterization as a left and right heart study. Other training programs have followed a different philos- ophy accounting for different catheterization habits, skills, and comfort levels in practice.

A final explanation that can be offered for the variability in right heart catheterizations is that in a fee for service, private practice environment, the operator is reimbursed more for the additional procedure. Some right heart catheterizations may be scheduled solely for the additional payment without any consideration for the best interests of the patient. Similar concerns could be raised about routine supravalvular aortography during diagnostic catheteriza- tions, a practice pattern I have commonly observed. These prac- tices cannot be tolerated and border on abusive behavior.

Clearly, more outcomes data on routine versus selective use of right heart catheterization is needed to resolve the controversy presented by this paper. At the hospital level, peer review and quality assurance committees may be able to monitor statistics on the usage rates by individual staff operators. Enforcement of re- strictions on right heart catheterizations would likely be difficult because definitions of suspected valvular heart disease or active congestive heart failure are difficult to develop. The problem, assuming there is one, will likely correct itself as managed care with “at risk” physician behavior becomes more widespread. When routine right heart catheterization is no longer profitable, and may even become a cost center, I believe that the variability in rates of utilization will narrow. Until then, we are all guided by our conscience to put patient concerns above our own.

REFERENCES

1 .

2.

Malone ML, Bajwa TK, Battiola RJ, Fortsas M, Aman S, Solo- mon DJ, Goodwin JS: Variation among cardiologists in the utili- zation of right heart catheterization at the time of coronary angi- ography. Cathet Cardiovasc Diagn. 37:125-130, 1996. Barron JT, Ruggie N, Uretz E, Messer JV: Findings on routine right heart catheterization in patients with suspected coronary ar- tery disease. Am Heart J 115:1193-1198, 1988.

0 1996 Wiley-Liss, Inc.