Arkansas project nearly eliminates routine bilateral catheterizations

Right caths add expense, risk, and do not improve care

Hospitals in Arkansas have nearly eliminated routine bilateral cardiac catheterization for Medicare patients undergoing angiography.

Participants in the Health Care Quality Improvement Program (HCQIP) of the Arkansas Foundation for Medical Care (AFMC), based in Fort Smith, made sure their state’s hospitals were aware that the use of right heart catheterization in conjunction with left angiography rarely yields useful information in the absence of right-sided disease. The American College of Cardiology/American Heart Association Guidelines for Cardiac Catheterization and Cardiac Catheterization Laboratories state that "without specific indications, routine right heart catheterizations . . . are unnecessary."1

Before HCQIP’s project, 80% of Arkansas hospitals performed bilateral heart caths only about a fifth of the time. Several outliers, however, performed the procedures at rates higher than statewide benchmarks.

"New York state’s peer review organization, IPRO, had conducted a similar study," says Sandy Grinder, RN, CPHQ, director of HCQIP at AFMC, "and they learned from cath lab directors that the possibility of finding unanticipated results from a right heart cath in conjunction with a left-sided procedure was in the range of 1%."

Several years ago, when Lake Success, NY-based IPRO ran its study, physician reimbursement in that state for a bilateral procedure was 60% more than for angiography alone. Left cath requires about 30 minutes of laboratory time, and personnel time cost was about $1,200. Investigators estimated that equipment and supply costs for right heart cath was approximately $300; and if the procedure required an additional 10 minutes of lab time, that would add another $400 for the second procedure, totaling $700.

The group concluded that right heart caths increased costs to the hospital without adding revenue. Those extra costs are not covered by the patient’s DRG, and the extra procedure exposes the patient to additional risk, such as allergic reactions, arrhythmias, myocardial ischemia, and perforation of the heart.

"The only time a concomitant right cath is appropriate is if coronary artery disease is complicated by clinically significant congenital heart disease, valvular heart disease, pulmonary hypertension, chronic obstructive pulmonary disease, or CHF," says Grinder.

The Arkansas group agreed that, like IPRO, they too could decrease the cost and risk to the patient if they could eliminate that unnecessary step.

First, they examined Arkansas facilities for variations in practice style. Most, they found, perform a right cath in a minority of their angiographies. A few outliers, however, did have high percentages of bilateral procedures.

In 1995, William E. Golden, MD, principal clinical coordinator of AFMC, sent a letter to its state’s hospitals presenting those statistics and asking them to participate in a project aimed at reducing bilateral caths except where necessary. The letter stated that:

• Right catheterization is a procedure of diminishing importance and diagnostic value when in conjunction with left heart angiography.

• Bilateral catheterization in the absence of clinical indication increases risks to the patient and cost to the system with minimal, if any, benefit to the care of the individual.

• Hospitals should review their performance of cardiac catheterization to see if there is a need for local guidelines on the procedure.

Golden’s letter requested a response from the facilities outlining the impact of those findings. Hospitals were asked to assess their use of bilateral caths and report what actions had been taken to modify care.

The letter was well received, says Grinder, and resulted in active discussions at medical staff meetings and prospective auditing of catheterization use. Many hospitals targeted a bilateral cath rate of 1% to 20% as an institutional benchmark.

"This was our first project that looked at resource utilization as opposed to compliance with a practice guideline," says Golden. "That made us nervous, because this had some implications about changes in revenue."

A bilateral cath potentially costs the hospitals, but there is a financial incentive for the providing physicians. Performing a cath in an inpatient setting is DRG-based, so the hospital has a fixed reimbursement. The addition of the second procedure increases the costs associated with cath lab time as well as supplies. There was a cost-effectiveness issue for the facilities; but for the physicians the project had income implications. More money went into the pocket of physicians who did right caths.

"There was a motivation on the part of facilities to look at appropriate use of those diagnostic techniques," he continues, "but one or two physicians in the outlier facilities were a little perturbed at the implications of the report. There were a couple of letters of protest from them. To our pleasant surprise, the institutions and their medical staff committees held their ground."

The committees set up monitors to oversee and review the physicians’ practice patterns, and made institutional decisions — they expected to see different behavior.

"That required commitment on their part to set local practice standards," says Golden. They told the providers that they had to alter their style of practice.

"Prior to releasing the project, the Arkansas chapter of the College of Cardiology reviewed the concept and endorsed our cited guideline on the utility of bilateral cath," says Golden. "When physicians voiced objections to the project, they were swimming upstream not only against their colleagues at the facility but against their professional society as well."

When HCQIP remeasured, there was considerable reduction in bilateral caths. Few outliers with rates above 20% remained. Two years after the letter to Arkansas hospitals, a follow-up was sent that included an analysis of more than 7,000 cases. (See graphs, p. 2.)

Overall, stated the letter, the use of bilateral heart caths had declined in a statistically significant fashion from the initial study period. Today, two facilities performing 13% of all catheterizations account for a third of the state’s bilateral procedures.

"Twenty-eight hospitals participated in the project," says Grinder. "Only two facilities increased their bilateral caths, and that was because they weren’t doing caths at all when the project began. They were going from zero to a low number."

Grinder points out the significance of the fact that nonparticipating hospitals had little improvement while participating hospitals had a significant drop in bilateral procedures. Arkansas now has one of the lowest rates of bilateral catheterization in the country.

"Any organization could replicate our study and show improvement in its rates," she says.

Reference

1. Pepine CJ, Allen HD, Bashore TM, et al. ACC/AHA Guidelines for Cardiac Catheterization and Cardiac Catheterization Laboratories. Circulation 1991; 84:2,213-2,247.