Guidelines: Good, bad & unreimbursed

Various guidelines appear to be under the magnifying glass these days, with dissenters challenging the need to follow recommendations. This may be part of a healthy debate. But how about instances where cardiologists are penalized for following evidence-based recommendations?

This week, physicians outlined their differences with two separate published guidelines for the management of patients with high blood pressure and patients with high cholesterol levels.

Five members of the Eighth Joint National Committee explained why they disagreed with a recommendation to change the target systolic blood pressure from 140 to 150 mm Hg in some people 60 years old and older. They argued the evidence was not sufficient to make the change and that it would lead to waning intensity of treatment in a high-risk patient population.

Also this week, a team of cardiologists from the Cleveland Clinic spelled out what they considered to be the pluses and minuses of American College of Cardiology (ACC) and American Heart Association (AHA) guidelines that are designed to reduce the risk of atherosclerotic cardiovascular disease. The authors focused on the guidelines dealing with high blood cholesterol and presented hypothetical cases of a patient in each of four major statin treatment groups.     

They praised some aspects of the guidelines but found fault with limitations imposed by the guideline writers’ adherence to using evidence from randomized clinical trials. Guidelines in the past incorporated other data and expert consensus to widen the net of recommendations to include scenarios commonly seen in clinical practice. They also took aim at a new risk calculator, which they described as untested.

The Cleveland group disagreed with the guideline’s abandonment of treatment goals for low-density lipoprotein cholesterol and high-density lipoprotein cholesterol, pointing out that tracking cholesterol levels after initiating therapy helps motivate patients and provides guidance for cardiologists on treatment decisions. They recommended combining parts of the new guidelines with previous recommendations that set cholesterol targets.

In a Q&A with Cardiovascular Business, the presidents of the ACC and AHA discussed the guideline process, what they recognized as controversial aspects of recommendations and limitations that would be addressed in future iterations. They emphasized the goal of getting physicians to talk with patients about their choices and lifestyle changes that may affect outcomes and observed that controversy over the guidelines heightened awareness and stimulated conversation among professionals.

On a troubling note, cardiologists and electrophysiologists who try to follow appropriate use criteria and guidelines on implantable devices for patients with arrhythmias may be at risk of an audit. A viewpoint in the Journal of the American College of Cardiology showed how the National Coverage Determination is out of step with contemporary evidence and offered options.

The AHA and ACC may well have stirred the water, and for the better. Discussion and close review of guidelines should help refine them. The next step may be getting policy makers in the conversation to ensure reimbursement for recommendations that improve patient care.     

Candace Stuart

Cardiovascular Business, editor