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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
Good sense again Sue there being no doubt that time spent building rapport with patients rather than ordering tests greatly diminishes the chance of being sued. The vast majority of litigation that I have commented on involved not acting on clear clinical signs &/or ignoring test results NOT on failing to order tests. For decades I have regarded overservicing to avoid litigation as the crutch of the inept and inadequate!
One of the real confounders in this area is the difference between tests to rule out the disease and tests to predict the outcome. When a patient presents to ED with chest pain, the aim acutely is not so much to identify coronary disease as to choose which patients should be kept for admission or immediate intervention due to a risk of an adverse cardiac event. What has changed over time, however, is that this risk is getting smaller and smaller, and yet we are getting more and more afraid of imperfection. The risk of a person dying of AMI after an episode associated with a normal ECG and normal vital signs is already low. Add a series of troponins, and it is even lower. Similarly, any subsequent intervention should also be justified by improved mortality or adverse event rates, not just treatment of the disease. We already have wards full of chest pain patients with a very small capture rate for AMI. We have too many test-orientated outcomes and not enough patient-orientated ones. All the same, people will always die unpredictably of a cardiac death. The best way to avoid being held responsible is to help the patient and their family understand the limits of predictability.
Just a brief comment on Coronary CTA. It has a Medicare item number since 1 July 2011. In order to receive the rebate, it must be a specialist referral, meet one of the 3 indications and be reported by someone accredited by the conjoint committee on coronary CTA. The indications are in essence: 1) symptomatic patient with possible coronary ischaemia 2) exclusion of coronary anomaly / fistula 3) patients undergoing non-coronary cardiac surgery eg. valve replacement. There are limitations and pitfalls to coronary CTA and the test itself may be open to abuse. The Cardiac Society of Australia & New Zealand has published guidelines and a recent review can be found in March issue of MJA.
I believe two ‘fears’ drive the direction of medical practice making it both more expensive and mechanistic and, at the same time, reduces the value of the human element in doctor patient relationships. They are concerns about being reported to AHPRA or the Health Commissioner and the irrefutable issue that Dr Jelinek raises, that is the need to be defensive to reduce the risk of being sued. Even when using best practice it is essential to get documented acknowledgement of potential complications and failures. Medicine today is not just about patients.