The Maryland Chapter of the American College of Cardiology (ACC) and the Society for Cardiovascular Angiography and Interventions (SCAI) have reiterated their call for the state of Maryland to require “rigorous internal and external review of stenting practices in hospitals in the state after an advisory group recommended a lower standard.” Simultaneously, a report has emerged of a new case of “improper stenting” in the state.

The Baltimore Sun reported Dec. 14 that John Chung-Yee Wang, MD, who heads the cardiac catheterization lab at Union Memorial Hospital in Baltimore is accused of improper stenting in three separate legal claims. Wang also is reportedly a colleague of Mark G. Midei, MD, who had his medical license revoked in July on similar charges while working at St. Joseph Medical Center in Towson, Md.

“By requiring each hospital to submit a written plan on an annual basis detailing how it will conduct regular internal and external review of its stenting practices, the state will be enacting important protections for Maryland’s patients,” said Samuel D. Goldberg, MD, president of ACC's Maryland Chapter.

The Maryland Health Care Commission’s (MHCC) Technical Advisory Group (TAG) recommended giving the Commission authority to regulate stent services as well as continuing evaluation of hospitals with stent programs, but the group stopped short of requiring an internal review that meets specific standards and an external peer review as an auditing mechanism.

Two high-profile stenting cases—Midei and Kourosh N. Mastali, MD—in Maryland hospitals were the result of “inadequate, voluntary, internal review,” Goldberg and SCAI President Christopher J. White, MD, said in a letter to MHCC, which is considering the advisory group’s recommendation. The medical societies are recommending a two-pronged system of checks, including an internal review process combined with regular audits through external peer review.

Additionally, the TAG draft recommendation to expand MHCC's “oversight” to CABG facilities is “excessively vague. It is unclear what authority this would give the MHCC,” according to SCAI and the Maryland Chapter of the ACC. They asked: Would MHCC have the ability to revoke PCI hospital certification? Would MHCC extend its current mandate for minimum PCI volumes to all physicians and hospitals? Recommend sanctions against cardiovascular providers?

In the letter, the societies issued these recommendations for transparent peer review and the use of data registries:

1. The root cause for the failure of PCI services at two Maryland hospitals was inadequate, voluntary, internal review and a culture of acquiescence to medical hierarchy with conflict avoidance. MHCC’s position is that clinical leadership at each hospital can assure compliance with quality and safety standards.
2. We acknowledge that hospital peer review activity has been significantly strengthened since these events became publicly reported through sharing of best practices by Maryland Hospital Associations' Necessary Care Work Group and the leadership of cardiologists at each institution.
3. We applaud the collaboration for voluntary external peer review by the University of Maryland and Johns Hopkins Hospital. This model has the potential to serve many hospitals in Maryland. But in reality, external peer review (PR) is optional and there is no guarantee to prevent internal PR from sliding back.
4. MHCC has demonstrated national leadership in the mandatory use of ACCF-NCDR Registry for Cath/PCI and Action/GWTG and hospitals have the same NCDR data. Hospitals will use this to drive internal review of aggregate performance, enhance accuracy of data entry and develop action steps for performance improvement. Most of this is achieved through selected case review.
5. Mere reporting of NCDR data is meaningless without critical analysis of the data that leads to performance improvement.
6. The foundation for strengthened internal and external peer review is a robust system of oversight and accountability. To distinguish from formal PR, we would organize this administratively under a “Cath Lab PI Committee.” Minutes should be kept and practitioner names de-identified. A quarterly report of quality and safety would be made to share with senior leadership – and such a report could be sent to MHCC for oversight. Since all of this work is a natural part of internal review, there is no additional burden for the hospital to send such a quarterly report to MHCC.
7. Voluntary oversight will be highly effective for those institutions with a true commitment to quality healthcare.
8. Voluntary oversight provides no guarantee that all citizens in Maryland are afforded equal, high quality healthcare as evidenced in comment #1 above. Over time, the risk is that the foundation of PR weakens.
9. With NCDR data, the MHCC can identify outlier performance. The collaborative approach for MHCC, hospitals, and physicians is for MHCC to initially inquire into, not investigate, areas of concern. Reports from cath lab performance improvement committees, appropriately de-identified as to patient and practitioner, will indicate that the hospital identifies and implements action steps for improvement.
10. MHCC can identify hospitals having sub-optimal performance with inadequate internal PR. MHCC oversight will help these hospitals improve.
11. We agree that external accreditation of cath labs should not be mandatory.
12. We advocate for external PR. There are many options including #3 above. We believe that restoring public confidence in PCI services is significantly strengthened by unbiased, independent external review and we stand by our request for legislation that will establish a balanced Task Force on the PR issue.

The complete letter can be accessed here.