Targeted training for cardiac procedures: A controversial solution for curbing costs

The United States spends more money on health care than any other industrialized country; and in return, it is expected that patients receive the most sophisticated, state-of-the-art diagnostic procedures and treatment.

This is indeed true for both invasive and noninvasive cardiology procedures. This specialized care, unfortunately, comes at great financial cost. With the increased life expectancy and aging of the population, as well as an increase in cardiac morbidities in this aging population, it is highly likely that we will not be able to deliver this kind of sophisticated care to all of our patients without spending more money on health care or reducing reimbursement for cardiac procedures. Utilization of diagnostic procedures, such as transthoracic and transesophageal echocardiography, stress echocardiography and nuclear studies, has increased exponentially.

Udho Thadani

As the reimbursement for these procedures to hospitals and freestanding clinics (and to highly specialized cardiologists) is higher than seeing and talking to patients, there is an incentive to perform more of these procedures. The cost of diagnostic cardiac catheterization, coronary angiography and invasive cardiac interventional procedures such as coronary artery balloon dilation, coronary artery stenting and special procedures for cardiac arrhythmias performed by highly trained cardiologists is enormous, given the number of these procedures that are being performed on a daily basis.

Financial burden during training

Current recommendations and guidelines mandate that the specialist-cardiologists performing these invasive and noninvasive procedures complete at least 1 or 2 years of specialized training after completing 3 years of general cardiology training and 3 years of internal medicine training. Before starting their own practice, most of the subspecialists are already in great debt — to the order of $200,000 to $400,000 — because of the training costs incurred, as well as the low salaries they receive during their long training years.

It is not surprising that most cardiology training fellows opt for an interventional career so that they can earn a good salary and pay their debts. These highly trained cardiologists deserve and appropriately demand higher salaries in the current market place compared with their colleagues who provide routine but equally important clinical care to their patients.

The need for these noninvasive and invasive specialist-cardiologists is bound to increase dramatically because of the recent approval of new valve procedures that can be performed percutaneously without open heart surgery. The future availability of robotic procedures for the placement of coronary artery stents and heart valves will also increase this demand. Besides performing coronary artery and valve procedures, many invasive cardiologists are also performing peripheral vascular and carotid procedures. They learn to perform these procedures with hands-on experience during their extra year of interventional and noninvasive cardiology training.

It is widely acknowledged that besides attending medical school, one requires excellent hands-on training under close observation of an expert specialist to gain proficiency in performing these invasive and noninvasive procedures safely and effectively. I can attest to this from my own personal and prolonged training experience of nearly 13 years as a general and invasive cardiologist and also from observation of my colleagues who practice invasive and noninvasive cardiology on a daily basis and from a dialogue with my previous trainee fellows who have been in practice from 1 to several years.

Nowadays, many large, private group practices and university-based groups provide sophisticated cardiac care to their patients by referring them to specialists in the catheterization laboratory or in the electrophysiology ablation laboratories or noninvasive laboratories. The rest of the cardiac care for patients invariably falls on their colleagues in the setting of a coronary care unit or in the inpatient ward setting and during outpatient services. There is often a separate call schedule for the invasive and noninvasive cardiologists at most institutions.

Therefore, an obvious question is how — given the long training required at present — can one reduce health care costs related to cardiac procedures? It is possible to do so, but the proposed approach will likely not be popular with my colleagues or with the professional cardiac societies.

Radical proposals

After high school or college graduation, train dedicated and motivated individuals to become cardiac procedure (noninvasive and invasive) experts (CPEs) to carry out cardiac procedures that have been recommended by the general cardiologists. The training of these CPEs should bypass the current requirement of attending medical school and completing a prolonged and required residency and cardiology training that usually lasts for 11 to 12 years.

Instead, these individuals can be trained in 3 years by exposing them to 1 year of extensive and targeted education in cardiac anatomy, cardiac physiology and pathology, with simultaneous rotations on an acute cardiac care unit and in specialized clinics. After this initial year, those considered proficient can progress to hands-on experience, under the mentorship of highly dedicated and trained specialists working in high-volume centers. Those who gain proficiency and pass a hands-on examination can then be certified as CPEs. These individuals should receive a scholarship in return for the time and help they would provide with patient workup and cardiac procedures during their training. No or little debt would be incurred by the end of their training.

The subsequent cost of the care provided by these CPEs can then justifiably be capped at a reasonable and affordable level. I realize that such a drastic approach will meet with a lot of criticism from my colleagues, and to address this concern, I recommend a controlled study; placing these trainees with excellent mentors working in specialized and high-volume centers and comparing their achieved technical skills with cardiology fellow trainees, who have completed the usual 11 (or more) years of training. Comparison must be based on technical skills rather than on the basis of theoretical knowledge. Expertise and clinical-technical skills should be judged by a group of unbiased experts in the field who have no knowledge of the type of training of an individual. My gut feeling is that the CPEs will perform as well as the conventionally trained cardiology fellows.

To further allay the fear of my colleagues and the governing bodies, I recommend that backup support always be available, in case there are any procedure-related issues or complications. This backup support can be provided by skilled and experienced cardiology mentors (interventional cardiologist or noninvasive cardiologists).

Future use of robotics in cardiology will also be applicable to my approach discussed above, as the robotic manipulations by joystick require excellent hand-to-eye coordination and multitasking. In a recent study reported in the journal Aviation, Space and Environmental Medicine, college students, 18 years and older, who were expert video game players, but outperformed trained pilots on cognitive tests related to acquiring, identifying and tracking targets.

My recommendations can be extended to other cardiac procedures such as peripheral- vascular and carotid invasive and noninvasive procedures. In a continuation of my commentary here, a second part to be published next year will deal with the topic of reducing health care hospitalization costs and the cost of insurance premiums.

Udho Thadani, MD, MRCP, FRCPC, FACC, FAHA, is a consultant cardiologist and Professor Emeritus of Medicine/Cardiology at the University of Oklahoma Health Sciences Center and VA Medical Center in Oklahoma City. He is also a member of the CHD and Prevention section of the Cardiology Today Editorial Board.

For more information:

• McKinley R. Aviat Space Environ Med. 2011;82:635-642.