President's Page: Quality and Appropriateness of Care: The Response to Allegations and Actions Needed By the Cardiovascular Professional

Maryland state agencies and the U.S. Attorney’s Office for Medicare Fraud have launched a full-fledged investigation of alleged inappropriate use of percutaneous coronary intervention (PCI) by a small number of operators and allegations of substantial overutilization of stents at several Maryland hospitals (1). In addition, an ongoing investigation under the auspices of the Maryland Department of Health and Mental Hygiene and other regulatory agencies is in full operation. A final report is due before the Maryland state legislature reconvenes in January. In an effort to proactively respond to these allegations, the Maryland Chapter of the American College of Cardiology (ACC), in close partnership with the national ACC and the Society for Cardiovascular Angiography and Interventions (SCAI), developed a task force charged with restoring patient confidence and assuring Maryland lawmakers that processes can be put in place at hospitals to closely monitor cardiac catheterization laboratories (cath labs) and prevent similar allegations going forward. To date, the task force has met with all levels of state government, including the Maryland governor’s office, and has drafted innovative legislation regarding the oversight required to ensure delivery of optimal high-quality cardiovascular care in the state. The proposed legislation, entitled “The Maryland Cardiovascular Patient Safety Act 2011,” has several prominent supporters in both the Maryland House and Senate and provides an opportunity consistent with the goal of patient-centered, quality care. More importantly, it will provide assurance to a wary public through independent cath lab accreditation. The issues facing Maryland hospitals and cardiovascular professionals present an opportunity to illustrate how professional societies can take a leadership role in ensuring quality care in the areas of peer review, accreditation, and data management. The issue of quality and appropriateness of cardiovascular care has not been confined to the state of Maryland or to the field of interventional medicine. We have seen other high profile allegations of overutilization and questions of appropriateness across the country in reference to other areas of cardiovascular care (and, indeed, in numerous other areas of medical care). It is time for our profession to step forward locally, regionally, and nationally to take the leadership position in this vital area of patient care. This is a natural progression, since for many years, cardiovascular professional societies—and the field of cardiology in general—have been well ahead of other specialties in producing data from clinical registries and in developing quality and appropriateness guidelines (2). Internal peer review is the crux of a successful cardiovascular program, regardless of whether it is related to invasive or noninvasive disciplines. It is critical that peer review be performed in a standardized, impartial, and effective manner. Present processes for internal peer review in some hospitals are inadequate if not faulty. Internal processes must be clear, rigorous, and objective, selecting random cases and guarding against physicians reviewing their own cases. Cases need to be reviewed not only in terms of outcome measures but also on the basis of appropriateness. A standardized internal process must be followed by independent external oversight performed by an external physician body.