Plenty of cardiology debates remain unsettled

April 8, 2016

From the value of hospital 30-day readmissions to the best provider for heart-failure patients, physicians are passionate about several care-based arguments.

One of the closing programs of the American College of Cardiology’s (ACC’s) 65th annual Scientific Session and Expo in Chicago consisted of three quick, spirited debates on the use of hospital 30-day readmissions as a quality measure, whether heart-failure specialists were the only physicians who should treat heart-failure patients and whether implantable hemodynamic monitors were now a “must” in the care of heart-failure patients.

Each presenter gave a nine-minute argument followed by three minutes of rebuttal. A vote was taken before and after each debate to measure the audience’s opinion and whether they had that opinion changed by either argument.

30-day Measure

Defending the use of the 30-day measure was Farzad Mostashari, MD, co-founder and chief executive officer of Aledade, a Bethesda-based company that operates accountable care organizations across the country. The opposite view was argued by Gregg Fonarow, MD, director of the Ahmanson-UCLA Cardiomyopathy Center in Los Angeles. The pre-debate opinion of the measure was 38% approving, 62% opposing.

“This is not a cardiology measure, it is a system measure,” argued Mostashari, the former National Coordinator for Health IT at the U.S. Department of Health and Human Services. “This to say a hospital’s job doesn’t begin with admission and end with discharge.”

 

Fonorow countered by saying the measure is “almost universally despised” by cardiologists, uses faulty risk adjustment that produces misleading quality scores, results in increasing emergency department observation stays and may even be produce higher mortality rates in an effort to avoid readmissions.

“This isn’t what we want to be incentivizing,” he said.

Based on a small change in opinion, Mostashari “won” the debate, but Fonorow’s side still prevailed with a 59% to 41% majority.

Heart-failure Patients

Maria Rosa Costanzo, MD, with Midwest Heart Specialists in Naperville, Illinois, took the position that only heart-failure specialists should be in charge of taking care of heart failure patients. The audience agreed with her at the start by a 68% to 32% margin. But Costanzo and the audience were not prepared for the fierce argument put forth by Joseph Alpert, MD, a professor of medicine at the University of Arizona in Tucson.

Alpert totaled up the number of existing heart-failure patients and the predicted rate of growth of new ones, calculated how many new heart-failure specialists were needed to treat them, and then multiplied those figures by the cost of training and paying them. His conclusion: This would lead to bankrupting the country and possibly World War III.

“The Maria Rosa Costanzo plan would result in a major national disaster of epic proportions,” Alpert argued. But having intelligent primary-care cardiologists -- such as himself -- follow established evidence-based guidelines for treating heart-failure patients would result in cost-effective quality care while averting worldwide disaster, he concluded.

 

Constanzo cited study after study showing how cardiologist-directed care is best for heart-failure patients, but she couldn’t match the energy Alpert brought to the debate. The post-debate vote showed an even 50% split in the audience on the issue.

Implantable Hemodynamic Monitors

Maya Guglin, MD, medical director of the ventricular assist device program at UK Healthcare in Lexington, started with 81% of the audience opposing her position that implantable hemodynamic monitors were now a required component of heart-failure treatment.

Guglin, an expert on how congestion is a leading contributor to heart failure, showed a picture of a monitor smaller than a person’s fingertip.

“We know our patients are getting readmitted over and over again,” Guglin said, adding that the use of these monitors could break this cycle as they alert cardiologists to the most common symptom leading to readmission. “It’s congestion, congestion and congestion.”

J. Thomas Heywood, MD, director of the Scripps Clinic heart failure recovery and research program in San Diego, countered by saying “nothing is ever a must.”

He noted that it is still unclear who would benefit from implanted monitors as they don’t help healthy patients much and don’t do any good for those who are already too sick or those with other major illnesses who are likely to die from something else besides their heart failure.

In her rebuttal, Guglin argued that the monitors are new technology that will eventually provide some level of certainty to clinicians’ diagnosis. “When you can check something, don’t try to guess, just check,” she concluded.

Like Mostashari, Guglin won the debate by persuading more of the audience to her side, but her position was still in the minority as 78% of the audience still agreed with Heywood.