The panel of cardiologists who revised U.S. competency standards for coronary interventionalists acknowledged prevailing case-volume realities and cut the minimum number of cases recommended for active operators to 50 per year, down from a long-standing recommendation of 75 coronary interventions annually.
The Clinical Competence and Training Task Force, assembled by the American College of Cardiology, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions (SCAI), also made the linked change of halving prior recommended coronary-case volumes for catheterization-laboratory centers, with a new recommended minimum target of 200 cases per year per site, down from the 400 annual cases called for in the 2007 version of the clinical competence statement for cardiac interventions.
The 2013 revision, with a focus specifically on coronary-artery interventions, appeared online on May 8 on the websites of all three organizations (J. Am. Coll. Cardiol. 2013 [doi:10.1016/j.jacc.2013.05.002]).
Although the revised case numbers will likely be what first captures the attention of interventionalists and cath lab administrators, these changes were not the most central to the new revision, said Dr. Theodore A. Bass, professor and chief of cardiology at the University of Florida, Jacksonville, and vice chair of the task force. He focused on the diverse, 35-item list of core competency components that is the backbone of the new revision.
"It’s a much broader view of what competency involves," he said in an interview. "In the past, competency was taking an exam, or having a certain knowledge base. But now we realize that other skills are also extremely important," such as appropriate patient selection, using technologies in a safe and appropriate manner, and delivering patient-centered care, said Dr. Bass, who is also president-elect of SCAI.
The new statement "is the first cardiovascular competency statement to fully utilize the six-domains structure promulgated by the Accreditation Council of Graduate Medical Education and adopted and endorsed by the American Board of Internal Medicine," Dr. John Gordon Harold, chair of the writing committee, said in a written statement.
"It goes beyond medical knowledge and procedure performance to include the important issues of leading an interdisciplinary team, working in a complex system, communicating effectively, engaging in continuous quality improvement at individual and system levels, adhering to evidence-based medicine, and demonstrating the highest levels of professionalism," said Dr. Harold, who is also ACC president and a cardiologist at Cedars-Sinai Heart Institute in Los Angeles.
Although the new statement is wide ranging, the case-number issue stands out as something the task force worked on at length, with a quarter of the statement devoted to various aspects of the issue for both individual operators and for cath labs.
"Volume has been used as a surrogate for quality because it measurable, but there has never been clear data that there is a strong correlation," said Dr. Bass. Plus, the original individual volume number, the venerable figure of 75 cases per year that has been around since at least 1990, when it appeared in the first clinical competency statement, "was not data based, it was judgment based," he noted. "Volume is not the be all and end all. We thought that 100 cases over 2 years seemed in the sweet spot for all considerations."
"Low-volume operators can self restrict what they do and get very good outcomes with less volume," said Dr. Christopher J. White, professor and chair for cardiovascular diseases at the Ochsner Clinic, New Orleans, and a member of the task force. "Rather than use an arbitrary volume as a surrogate for quality, it is more useful to actually measure quality, with a tool like the NCDR [National Cardiovascular Data Registry] for CathPCI."
Another issue is the feasibility of calling for annual rates of 75 cases individually and 400 per center, given recent trends with substantially fewer U.S. percutaneous coronary interventions (PCI), compared with the mid-2000s, and the growing number of interventionalists. The statement notes that "a majority of interventional cardiologists in the United States are not achieving the previously recommended threshold of 75 PCIs annually."
Also, these days most interventional cardiologists perform other types of procedures that may not count as PCIs but still keep their skills sharp – things like peripheral vascular procedures, carotid stenting, and transcatheter aortic valve replacements, Dr. Bass said. And there is the issue of society’s need to have important acute-care services like primary PCI for myocardial infarctions available in even remote areas, where higher case volumes are hard to maintain.
"Cath labs with fewer than 200 cases per year should examine what they do and have stringent quality assurance measures in place," he said.