The chief of cardiology at the University of Florida College of Medicine-Jacksonville, Ted Bass, M.D., has recently been cited in a large number of professional journals and online news feeds within his field for a paper for which he was vice chair of the writing committee and one of the lead authors. This publication is considered ground-breaking in the world of interventional cardiology. Bass, who was inducted as president of the Society for Cardiiovascular Angiography and Interventions at the society’s annual meeting in May, said in an interview with Cardiology News that he believes that part of the reason for the attention that the paper has garnered is its enlarged view of the issue of competency.
"It’s a much broader view of what competency involves," he said. "In the past, competency was taking an exam, or having a certain knowledge base. But now we realize that other skills are also extremely important." Bass defined those skills in the paper as appropriate patient selection, using technologies in a safe and appropriate manner, and delivering patient-centered care.
The updated statement, which features input from the American College of Cardiology, American Heart Association and Society for Cardiovascular Angiography and Interventions, highlights new and adjusted benchmarks to assist with measuring and evaluating operator and institution performance of coronary-related procedures.
John Gordon Harold, M.D., chair of the writing committee, said that the revision "is the first cardiovascular competency statement to fully utilize the six-domain structure promulgated by the Accreditation Council of Graduate Medical Education and adopted and endorsed by the American Board of Internal Medicine."
Currently, procedural volume is widely used as a surrogate for competency, with the belief that higher volumes equate to greater success rates in percutaneous coronary intervention (PCI), particularly improved clinical outcomes. According to Bass, who was the vice chair of the writing committee of the statement, one of the problems with using this metric alone is that procedural volume for coronary interventions has changed, decreasing by more than 30 percent since 2006, while the workforce has not changed.
"Volume has been used as a surrogate for quality because it is measurable," he said to Cardiology News. "But there has never been clear data that there is a strong correlation."
While the 2013 revision, with its focus on coronary-artery interventions has caught the attention of interventionalists and catheterization lab administrators with its startling revision of case numbers, Bass is quoted as saying that these changes were not the most central to the revision. Instead, he emphasized the importance of the diverse, 35-item list of core competency components that is the backbone of the new revision.
Bass explained that this list takes into account that the range of procedures interventionalists are now doing extends beyond PCI to valve, peripheral vascular and other procedures that require many of the same skills and knowledge.
Bass stressed in an interview with TheHeart.org that most interventional cardiologists today perform other types of procedures that may not count as PCIs but still keep their skills sharp – things like peripheral vascular procedures, carotid stenting and transcatheter aortic valve replacements. He reiterated the issue of society’s need to have important acute-care services like primary PCI for myocardial infarctions available in even remote areas, where higher case volumes are hard to maintain.
"Cath labs with fewer than 200 interventional coronary cases per year should examine what they do and have stringent quality assurance measures in place," he said.
Two other notable changes in the 2013 competency revision are the inclusion for the first time of radial-artery access as an identified competency. Radial access "is still just under 20 percent of all U.S. PCI but that’s up exponentially from a few years ago," Bass said. "There is a huge amount of patient preference for it, and the next generation is now trained in it. Radial access is the future."
In an article for TheHeart.org entitled "High-volume gets demoted in new PCI-competence document," he said: "I'd like to think [the new document] is not reactive; I'd like to think that we are patient-centered and centered on outcomes. We are not just looking at hard clinical outcomes like mortality or bleeding, but we are also looking at the appropriateness of care."
In explaining the impetus for the timing of the update, Bass, speaking to Cardiology Today, said: “Another reason we updated this statement is because it is no longer satisfactory to just have cognitive competence, which is just one of the components.
"The new revision focuses exclusively on coronary artery interventions, with other common cardiac percutaneous procedures like valvuloplasty on hold for a different competency task force that will deal with structural and non-coronary interventions."
Bass was further quoted in the Cardiology Today article, "Societies update clinical competencies needed for performing PCI" by saying: "Now we are looking at not only what people know, but also what skills they have and how they apply their skills and knowledge, and eventually the final result. Because what our patients want to know is not how smart their doctors are, but how competent they are — are they delivering optimal health care?"
"It's been six years," Bass said, "and the landscape of what we do has changed and our understanding of how we define physician competency has also evolved. It was time for an update."