November 2014: Evidence-based Guideline Subcommittee (EbGS) of the Health Evidence Review Commission (HERC) presents an initial draft coverage policy for percutaneous coronary interventions (PCIs) in patients with stable ischemic heart disease (SIHD). The EbGS recommends that PCI should be covered for patients who had a recent myocardial infarction and for female patients but PCI should not be covered for patients over age 75 and men with stable angina.
May 2015: EbGS releases, and HERC adopts, a final coverage guideline for PCI in SIHD patients. The coverage guideline states that coronary revascularization (PCI or CABG) is recommended for patients with stable angina whose symptoms are not controlled with optimal medical therapy or who cannot toler-ate such therapy. The final policy represents a considerable change and is much more consistent with ACC/AHA/SCAI practice guidelines.
What happened in the six months between these two milestones illustrates how much the well-being of patients depends on the active and positive engagement of practicing cardiologists in policymaking.
In Oregon, the Evidence-based Guideline Subcommittee is a powerful body. To a large extent, it determines what Oregon’s Medicaid program will and will not pay for. Its policies guide coverage decisions for Oregon state employees and teachers’ health plans. Other health plans often model their coverage on EbGS policies. EbGS basically determines the care that up to one-third of Oregon’s population are be able to access.
The initial EbGS draft coverage policy for PCI in SIHD was well-intentioned, but it was written by staff who hold degrees and experience in healthcare policy. They are not and have never been clinicians. These policymakers based their recommendations on an evidence base derived primarily from the Agency for Healthcare Research and Quality (AHRQ), relying on published meta-analyses from 2009 or earlier. The only randomized clinical trial included in their literature review was COURAGE. The remainder of the cardiology literature, including clinical guidelines, were considered “low-quality” evidence.
The EbGS staff should be commended for the effort they put into improving their draft policy and their commitment to protecting Oregon’s patients, but it must be said that without the perseverance and en-gagement of cardiologists the initial coverage draft might very well have passed unchallenged.
Fortunately, that’s not what happened.
Between November and May, the draft coverage document underwent three revisions, each reflecting the comments, clinical perspective and recommendations of cardiologists.
What Did I Learn?
Before November 2014, my involvement in advocacy activities was relatively minor. I was a member of SCAI’s Advocacy and Government Relations Committee. I attended meetings and paid attention and on some level I recognized that the physician voice was fading from many critical discussions on healthcare policy, particularly in Washington, D.C.
When this issue arose in my own backyard—brought to my attention by colleagues at SCAI—I found myself on the front line of a policy issue that could drastically restrict my patients’ access to medically necessary care. What I learned is that, by working together, we physicians can make a big difference, but we must be willing to learn new skills and take on tasks that are very different from what we were trained to do. It turns out that this work also can be very relevant to my goal of taking the best possible care of my patients.
What almost happened in Oregon is not an isolated situation. We have seen similar activities in Washington state and New York, and I suspect we will see them in more states in the future. Are you ready to be your patients’ advocate?
Drilling Down: What Oregon Taught Us
- The Evidence-based Guideline Subcommittee in Oregon were using flawed and incomplete data. Their “review process” was guided by rules so strict that they excluded the practice guidelines of professional medical societies.
- The staff are responsive to reasonable input.
- Providing clinical context is effective. It helps non-clinicians bridge the gap between data and patient care. In this case, explaining specific clinical scenarios resulted in the EbGS agreeing to remove gender and age restrictions and to recommend PCI for SIHD patients in whom medical therapy is ineffective or cannot be tolerated.
- Advocacy can be a slow and tedious process that requires continuous engagement, meticulous at-tention to detail and patience. But it is worth the effort.
Dr. Toggart is an interventional cardiologist employed by the Samaritan Heart and Vascular Institute in Corvallis, Oregon. He is director of quality improvement, cath lab and interventional cardiology fellowship program. He has participated in multi-center trials such as Horizon and CORAL.