Experts at the medical associations argue that the term “inappropriate” was not meant to indicate that a procedure in particular patient situations is never indicated, noting that such judgments are based on patient records that don't necessarily capture the full range of patient needs and symptoms.
“No one expected that the inappropriate rate should be zero,” said Dr. Manesh Patel, director of interventional cardiology at Duke University Health System and chairman of the Task Force on Appropriate Use Criteria for the American College of Cardiology. “Therefore we changed the term to 'rarely appropriate,' which is more in keeping with the idea that there may be patients in circumstances that fall outside those windows.”
The language change comes at a time of increasing professional and public concern about overuse of stents, and increasing scrutiny by insurers and government agencies. It applies to guidelines on more than a dozen specific cardiac procedures. The revascularization guidelines, which are due to be revised in the next year, will apply the wording change to stents.
In the past few years, at least four hospitals have settled stent-overuse allegations without admitting wrongdoing. And three cardiologists have gone to prison based on evidence that their patients didn't have enough arterial blockage to justify using stents and that they changed the medical records to show more blockage than existed.
Despite the terminology change, Dr. John Harold, president of the ACC and a cardiologist at Cedars-Sinai Heart Institute in Los Angeles, acknowledged that sometimes a service is not “rarely appropriate,” it's always inappropriate. He said inserting a cardiac stent without the degree of arterial blockage that meets clinical criteria should always be considered inappropriate. But those cases are fraud, he said, and the designations appropriate, inappropriate, or rarely appropriate don't apply.
Follow Joe Carlson on Twitter: @MHJCarlson
