• Coronary computed tomographic angiography and a shout-out to SMART EM

    I’m tremendously enjoying the SMART EM podcasts, about which I may write more in the future. For now, if you’re interested in evidence-based medicine, parsimonious use of medical resources, and/or patient centered care, I encourage you to check it out. The one on coronary computed tomographic angiography (CCTA) included a reference to a NEJM letter by Drs. Schuur and Kosowsky that reads, in part,

    CCTA did not improve patient safety. [Low risk] patients [] (rate of acute myocardial infarction or death during the index visit, <1%) who underwent CCTA were no less likely to have an acute myocardial infarction or cardiac death at 30 days than patients who received traditional care. CCTA only reduced the use of provider-discretionary health care services — admission to a hospital or an observation unit. CCTA may provide a psychological benefit to physicians, but it cannot be justified from a patient’s perspective. Patients who underwent CCTA were exposed to the risks of contrast-induced nephropathy and ionizing radiation. The use of CCTA led to the diagnosis of coronary artery disease — a radiologic diagnosis of unclear value — in 1 of 20 additional patients. How should clinicians explain this diagnostic strategy to patients? “Sir, although you only have a 1 in 100 chance of having a heart attack in the next month, I do not feel safe sending you home. So, I ordered an expensive test that will not reduce your risk of a heart attack, but it could cause kidney damage or cancer.” This is not “choosing wisely.” [Emphasis added.]

    Shorter: It’s time to wake the f*** up.


    • Of course, the important and controlling factor here is that it increases the doctors income.
      The only way to prevent these unnecessary tests is to remove this incentive. The doctor gets no money from the test. Pay the doctor by the outcome, not the test.

    • @Mark Sophr: Cardiologist orders CCTA. Radiologist performs and reads CCTA.
      The cardiologist does not get paid for ordering CCTA. There is no CPT code for that. Radiologist gets paid for CCTA. But he /she can not order CCTA.

    • But that does not preclude the Cardiologist from having a financial interest in the clinic that owns/operates the CCTA machine.

      And is “defensive medicine” still an issue?

    • The supposed check and balance does not work. False positives from the test result in cardiac caths (which do profit the cardiologist) hospitalizations profit the hospital or health system and reading of the radiology tests profit the radiologists. The company that provides the machines and software for the CTCC profit. Wow, hard to believe anybody believes profit is not driving this test. A good example of lack of adequate cost/benefit analysis.

    • So do we know what percentage of practicing cardiologists own or have financial interest in imaging centers which perform CCTA? Doesn’t Stark Law prohibit such arrangement?
      How about those salaried cardiologists in academic institutions? Do they not order CCTA?