Due to recent highly publicized controversies of alleged over-stenting, state and federal authorities have begun to question the peer review process in cath labs. As a result, professional societies are exploring a new accreditation process, but some providers fear the time and costs that this could entail.
Peer review process
“In cath labs throughout the U.S., we need to eliminate some of the common variations that occur with the internal peer review process from hospital to hospital,” says Mark A. Turco, MD, director of cardiac and vascular research at Washington Adventist Hospital in Takoma Park, Md., which performs approximately 25 to 30 cases—diagnostic and interventional—daily in its five cath labs.
At Washington Adventist, the cath lab director chairs the internal peer review process, in which a representative group of cath lab operators reviews the cases on the first Friday of every month. “Performance measures are quality markers that drive much of the reviews, and our staff documents deviations from appropriate performance,” Turco explains. “It is critical that the internal peer review committee not only reviews adverse patient outcomes, but also the appropriateness of procedures—what was done, why it was done and how it was done.”
In an effort to avoid bias at Washington Adventist, cardiology partners cannot review each other’s cases. Also, the provider has embraced the growing trend of an oversight peer review committee, whose multidisciplinary members are appointed by the hospital’s medical executive committee.
However, cath labs provide diverse services and for varied patient populations, so the make-up of each lab is different. “Most of the cardiologists who service our facility are privately-based,” explains Roshan K. Mathew, MD, medical director of the cardiac cath lab at Owensboro Medical Health System in Greenville, S.C., which performs about 2,000 cath lab procedures annually with 11 cardiologists—nine of whom are interventionalists. Owensboro has established a cardiology services committee, which consists of all the local cardiologists, and a chair and a vice chair. Independent of the committee, the medical director runs the cardiac cath lab.
Initially, at Owensboro, peer review was conducted by the committee, but that has since been changed, so there are “no inter-group conflicts,” says Mathew. Now, the peer review process is conducted by two cardiologists, the medical director, the chair of the cardiology services committee, along with three independent physicians—from internal medicine, the emergency department and surgery—who track and trend the National Cardiovascular Data Registry (NCDR). This process falls under the quality department, which has a separate chair who assigns the members of the review process. The medical director only deals with “dramatic issues,” while the committee votes on most of the considerations.
“The process mainly tracks complications,” Mathew says. “A quality review of individual operator usage is very difficult to assess, and we are currently seeking a better evaluation method. The problem with tracking complications is that high-volume operators will naturally have higher complication rates, but it is not necessarily reflective of technique.”
Most practitioners and administrators concur that the current systems in place aren’t perfect. “In an ideal setting, an unbiased committee would track independent quality assessments, along with complications, which would include the evaluation of FFR [fractional flow reserve] and intravascular ultrasound usage,” Mathew says. “Inevitably, we need to make tough decisions about whether physicians are performing appropriate procedures, as established by the clinical guidelines.”
Turco stresses the importance of documentation, potentially employing a pre-cath checklist that clearly states the reasons for moving forward with a procedure.
However, some still are seeking external oversight to ensure the cases are being handled and reviewed appropriately.
Society accreditation = excellence?
The Accreditation for Cardiovascular Excellence (ACE), a nonprofit initiative supported by the Society for Cardiovascular Angiography and Interventions (SCAI) and the American College of Cardiology (ACC), was formed approximately five years ago in response to CMS' stipulations about accreditation for institutions performing carotid stenting. Approximately one year ago, ACE undertook the goal of providing accreditation for all invasive