In this issue, we talk with cardiologists who are looking at the introduction of new pharmaceuticals that could prevent stroke in some atrial fibrillation patients. Drugs such as dabigatran (Pradaxa, Boehringer Ingelheim), rivaroxaban (Xarelto, Bayer/Johnson & Johnson) and potentially apixaban (Eliquis, Bristol-Myers Squibb) could offer a welcome alternative to warfarin in the anticoagulant market.
But testing an investigational drug in a randomized, controlled clinical trial is not the same as prescribing a drug in the patient population, as cardiologists know. Factors that were not apparent in trials may influence outcomes in ways not anticipated. Quite rightly, cardiologists are cautious while also excited about the prospects of new drug choices.
I began thinking about unintended consequences after a conversation with Robert C. Hendel, MD, director of cardiac imaging and outpatient services at the University of Miami Miller School of Medicine in Florida, and chair of the writing group on 2009 guidelines for appropriate use of cardiac nuclear imaging. He was comparing the use of radiology benefits managers (RBMs) with decision support tools and an educational initiative developed through the American College of Cardiology (ACC).
The RBM approach is punitive, he said, while the ACC approach was non-threatening and provided feedback components to help physicians and hospitals identify opportunities for improvement.
I suspect regulatory agencies and payors might not be concerned if an approach is a carrot or a stick, as long as it meets the goals of reducing unnecessary overutilization. But they may not have foreseen the incentives, or disincentives, embedded in the RBM process.
It struck me that the RBM method rewards keeping physicians in the dark if RBM reimbursement is tied to the denial of imaging requests.
Wouldn’t it be more lucrative to have physicians repeat such ordering patterns rather than educate them about appropriate use?
That was certainly not the intent. It is difficult to foresee downstream effects, but any endeavor tempered by caution seems a wise course of action.