Michael Jelinek: Overservicing a legal necessity

QUESTIONS have been raised about the routine diagnostic testing of patients admitted to the emergency department with suspect acute coronary syndromes.

An article in the Archives of Internal Medicine suggested that, while routine diagnostic testing resulted in an increase in the rate of diagnosis of coronary artery disease and an increase in cardiac revascularisation rates (percutaneous coronary intervention [PCI] and coronary artery bypass graft [CABG]), this was not accompanied by a reduction in the rates of new myocardial infarctions.

The authors of the article concluded that the practice of guideline-recommended management was an essential cause of overservicing in this group of patients. They thought this practice might be reversed if randomised controlled trials (RCTs) showed no improvement in outcomes in this situation.

In my dotage, much of my work is in medicolegal matters. I know many doctors are being sued by the families of patients who have died after being seen with suspicious chest pains in emergency departments or in general or specialist office practice.

They are being sued even if they have followed the practice guidelines but the patient has subsequently died. This is a major incentive for the minimisation of missed myocardial infarctions.

The problem is how to minimise PCI or CABG that might arise from unnecessary coronary angiography. Certainly negative stress/imaging tests in this context should not lead to coronary angiography.

But how do doctors cope with positive or equivocal stress tests? If the result of this positive test does not fit the clinical picture, computed tomography coronary angiography (CTCA) would appear to be a valid method of reducing unnecessary coronary angiography and intervention.

However, CTCA is not widely available and, in the private health care system, attracts a fee of around $500. This fee is not covered by health insurance. It therefore results in less well off patients, who cannot afford the fee for CTCA, receiving invasive coronary angiography.

If the CTCA shows heavy coronary artery calcification or atherosclerotic lesions in the coronary artery vessels, or there is history of known coronary artery disease, invasive coronary angiography is mandated.

The best hope for reducing unnecessary PCIs is the use of fractional flow reserve (FFR) technology to measure pressure differences across the stenosis. Not all narrowings that look tight on angiography cause ischaemia.

The FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study showed that if lesions that look tight but do not cause ischaemia measured by FFR are stented, the patient outcome is poorer than if such lesions are left alone.

Selective referral to cardiologists who use FFR technology may result in fewer unnecessary PCIs in the community.

Patients, their relatives and you — the practitioner — will not be satisfied with the results of RCTs, which are currently not available anyway.

Overservicing is a necessary cost incurred because of our medicolegal system.

Professor Michael Jelinek is a cardiologist at St Vincent’s Hospital, Melbourne.

Posted 15 October 2012