Whats up Cardio and ordering undeeded tests

[ventana]

I am seeing an ongoing trend with  Cardio folks way overshoot the mark on what they are ordering to r/o AMI and pre-op clearance. 

 

Just the other day I sent a 51 yr old WITH ZERO RISK FACTORS to the ER as he had 2-3 days of CP, and I just was not 100% comfortable with saying it was not cardiac with out a troponin.  Yup trop was NEG/to low to measure.

Cardio consulted by ER doc, recommends a NUC stress - which they call the patient the very next day to do in less then a week.  Meet with the patient urgently to discuss and he literally says HELL NO - he knows it is not his heart, he has no risk factors.  I try out the HEART app and he has a score of like 2 (4 and above needs work up)  And cardio has fast tracked him for a NUCLEAR study.  This guy can walk, run, and literally has not a single risk factor (no DM, HTN, lipids are perfect, BMI normal, No FMH at all, normal EKG)  

 

Why order a nuc study when every guideline says at most he needs serial trops,   leaning forward would be an exercise - never a nuc - - but of course the Nuc pays a lot more for the cardio doc....

 

 

Then I have lost count of the number of pre-op clearances which Cardio docs are ordering Cath's to clear people for low risk surgery in patient with NO symptoms - some are athletes who are certainly doing their "own stress tests" every time they ride their bicycles, or play basketball  ball or go running  - yet they are ordering caths on them for low risk procedures.....

 

 

What is going on?  is it being overly defensive, not knowing the guidelines or money making?  Lots of articles coming out lay press about cardio to way to many interventions has me wondering....

[CAAdmission]

You really have to ask? Cha-ching

 

[UGoLong]

I work in cardio and see a variety of behaviors in other practices. That said, people drop dead without risk factors and we’d understandably really don’t want that to happen on our watch.

 

A 51 yo man with unexplainable chest pain that subsides with negative troponins is probably going to get a cardiac workup. If no other risk factors, our practice would likely recommend an outpatient stress test. If the patient is reasonably active, it would probably be a treadmill or treadmill stress echo.

 

Just as you wanted to rule out an MI, a cardio practice wants to rule out ACS or ischemic heart disease. That’s one of the things we do.

 

 

Sent from my iPad using Tapatalk

 

[thinkertdm]

2 hours ago, ventana said:

I am seeing an ongoing trend with  Cardio folks way overshoot the mark on what they are ordering to r/o AMI and pre-op clearance. 

 

Just the other day I sent a 51 yr old WITH ZERO RISK FACTORS to the ER as he had 2-3 days of CP, and I just was not 100% comfortable with saying it was not cardiac with out a troponin.  Yup trop was NEG/to low to measure.

Cardio consulted by ER doc, recommends a NUC stress - which they call the patient the very next day to do in less then a week.  Meet with the patient urgently to discuss and he literally says HELL NO - he knows it is not his heart, he has no risk factors.  I try out the HEART app and he has a score of like 2 (4 and above needs work up)  And cardio has fast tracked him for a NUCLEAR study.  This guy can walk, run, and literally has not a single risk factor (no DM, HTN, lipids are perfect, BMI normal, No FMH at all, normal EKG)  

 

Why order a nuc study when every guideline says at most he needs serial trops,   leaning forward would be an exercise - never a nuc - - but of course the Nuc pays a lot more for the cardio doc....

 

 

Then I have lost count of the number of pre-op clearances which Cardio docs are ordering Cath's to clear people for low risk surgery in patient with NO symptoms - some are athletes who are certainly doing their "own stress tests" every time they ride their bicycles, or play basketball  ball or go running  - yet they are ordering caths on them for low risk procedures.....

 

 

What is going on?  is it being overly defensive, not knowing the guidelines or money making?  Lots of articles coming out lay press about cardio to way to many interventions has me wondering....

Q: What do you call a thousand lawyers chained together at the bottom of the ocean?

A: the answer to this problem

In other words: oh my God, they killed Kenny!

There you go.  Families don't understand risk factors, a lifetime of smoking and triple cheeseburgers, they only see YOUR  fault for not finding and stopping the problem.

[PAinPenna]

I will never document a pre-op "clearance". That's ultimately up to the surgeon and anesthesiologist . In our practice we call what we do "medical optimization" prior to surgery, never even use the word clearance anymore.  

Is that just us??

 

Should add -we are Family Medicine 

[ventana]

On 1/10/2019 at 8:03 PM, UGoLong said:

I work in cardio and see a variety of behaviors in other practices. That said, people drop dead without risk factors and we’d understandably really don’t want that to happen on our watch.

 

A 51 yo man with unexplainable chest pain that subsides with negative troponins is probably going to get a cardiac workup. If no other risk factors, our practice would likely recommend an outpatient stress test. If the patient is reasonably active, it would probably be a treadmill or treadmill stress echo.

 

Just as you wanted to rule out an MI, a cardio practice wants to rule out ACS or ischemic heart disease. That’s one of the things we do.

 

 

Sent from my iPad using Tapatalk

 

 

I totally disagree with some of this

Please show me even a SINGLE study or guideline that states in patient like I described, whom is perfectly able to walk and run that NUC should be ordered.  In fact if you follow the HEART guidlelines on the iphone app for ER proviers a score of less then 4 doesn't need anything beyond serial trops.

Sure work them up, IF EVIDENCE supports it, and with the right test.  But I see just to many cardio folks going to the most expensive test with out any awareness of false positives and the injury possible by doing unneeded studies.

 

One patient as a great example

 

73 yr old male, only risk factor was elevated lipids, not horrid just a little high.  Plays very competitive tennis, 2-3 times per week, started to do cycling races this summer right before this evaluation (maximal effort for 45 min).  Non smoker, healthy weight and diet.

PCP in FL did clearance for elective hip replacement "say something" on EKG and got a cardio consult.  They did a nuc stress (why not do a exercise was beyond me.  In the nuc report it said there was basically an attenuation error due to breathing but could not 100% say.  (Load of BS report)  They were VERY hesitant to release a disc with images.

After not discussion with the patient, and the risks of life long or 1 yr anticoag (they were advocating for a cath with STENT) in a healthy asymptomatic male he demanded a second opinion from a local university cardio.  

 

The short of it - he cleared him for surgery on the spot - then went on to state the the place that was recommending all these interventions had their own cath lab and just had purchased some new machine they were trying to pay for.  WHY ON GODS EARTH WOULD A DOC SELL THEIR MORALS LIKE THIS?

 

This was 4 years ago and the patient is fine s/p hip replacement and back to tennis and bikes.....  was a total money unethical money grab.  The PCP has since apologized to him for sending him there....

 

Their are some doc's that are just plain scumbags with medical degrees....

[EMEDPA]

I agree that a nuc is probably overkill, but a basic stress test is a simple, inexpensive and easy office procedure. I have done more than 80 in ED obs units for stories sillier than this. for a while we were treadmilling everyone in the ED with a c/o chest pain. 16 yrs old. hurts when you do push up only and you just started at a new gym last week? treadmill after 2 neg trops and a cxr. not my call. I don't work there anymore...

[bike mike]

Who the hell is ordering a LHC for pre op clearance for a pt with low probability of CAD? That is insane. When they eventually inadvertently cause a dissection on an otherwise healthy patient they’ll get sued for a pretty penny. 

[GetMeOuttaThisMess]

I agree that a nuc is probably overkill, but a basic stress test is a simple, inexpensive and easy office procedure. I have done more than 80 in ED obs units for stories sillier than this. for a while we were treadmilling everyone in the ED with a c/o chest pain. 16 yrs old. hurts when you do push up only and you just started at a new gym last week? treadmill after 2 neg trops and a cxr. not my call. I don't work there anymore...

 

Just to play devil’s advocate here. Back in late 80’s-early 90’s we were quoting ETT sensitivity rates at 85% on studies done in our cardio office.

 

I will add that when we had a false positive I’ve seen sails on boats shorter than the ST segment elevations.

 

[EMEDPA]

2 hours ago, GetMeOuttaThisMess said:

 

Just to play devil’s advocate here. Back in late 80’s-early 90’s we were quoting ETT sensitivity rates at 85% on studies done in our cardio office.

 

I will add that when we had a false positive I’ve seen sails on boats shorter than the ST segment elevations.

 

agree that in someone with risk factors your probably want more than a basic EST, but what about a 51 yr old guy with zero risk factors who is in great shape? imagine someone(say a marathon runner) with no No FH of ACS, good cholesterol, non-dm, non-smoker, bp 110/50, resting pulse 52, no recreational drugs, both parents still alive in their 80s and several prior good experiences with anesthesia for common stuff like ear tubes as a kid, appy as a 20 yr old, etc

[UGoLong]

13 hours ago, ventana said:

 

I totally disagree with some of this

Please show me even a SINGLE study or guideline that states in patient like I described, whom is perfectly able to walk and run that NUC should be ordered.  In fact if you follow the HEART guidlelines on the iphone app for ER proviers a score of less then 4 doesn't need anything beyond serial trops.

Sure work them up, IF EVIDENCE supports it, and with the right test.  But I see just to many cardio folks going to the most expensive test with out any awareness of false positives and the injury possible by doing unneeded studies.

 

One patient as a great example

 

73 yr old male, only risk factor was elevated lipids, not horrid just a little high.  Plays very competitive tennis, 2-3 times per week, started to do cycling races this summer right before this evaluation (maximal effort for 45 min).  Non smoker, healthy weight and diet.

PCP in FL did clearance for elective hip replacement "say something" on EKG and got a cardio consult.  They did a nuc stress (why not do a exercise was beyond me.  In the nuc report it said there was basically an attenuation error due to breathing but could not 100% say.  (Load of BS report)  They were VERY hesitant to release a disc with images.

After not discussion with the patient, and the risks of life long or 1 yr anticoag (they were advocating for a cath with STENT) in a healthy asymptomatic male he demanded a second opinion from a local university cardio.  

 

The short of it - he cleared him for surgery on the spot - then went on to state the the place that was recommending all these interventions had their own cath lab and just had purchased some new machine they were trying to pay for.  WHY ON GODS EARTH WOULD A DOC SELL THEIR MORALS LIKE THIS?

 

This was 4 years ago and the patient is fine s/p hip replacement and back to tennis and bikes.....  was a total money unethical money grab.  The PCP has since apologized to him for sending him there....

 

Their are some doc's that are just plain scumbags with medical degrees....

I hear what you're saying and I too do not see a reason for an in-hospital nuc stress test for the particular patient you described. And there is usually little reason for a stress test to clear an asymptomatic patient who already gets to 85% of the max age-predicted heart rate (220 - age) in his or her normal life. If they can't do that, then a stress test may be indicated for surgical clearance for the riskier surgeries. If a patient is not able to exercise (perhaps because their hip is getting replaced and it hurts too much to move), then a nuc can actually be an easier and faster test than the alternative: a dobutamine stress echo.

Screening guidelines to release someone from the ED by ruling out ACS are great and unclog your department without excessive risk. But it's not the same thing as what a cardiologist may decide to do on follow-up, nor should it be necessarily. That's why you have them follow up in the first place.

And let's not ride our own horses too high. I certainly don't endorse the behavior of everyone working in the same specialty that I do. On the other hand, for most of us, it's not an issue of "selling your morals" but of evaluating a given patient's risk.  I wouldn't assume everyone is trying to overbill. No one wants to be the one that blew off a symptom and didn't investigate further if that was called for. 

 

[GetMeOuttaThisMess]

16 hours ago, EMEDPA said:

agree that in someone with risk factors your probably want more than a basic EST, but what about a 51 yr old guy with zero risk factors who is in great shape? imagine someone(say a marathon runner) with no No FH of ACS, good cholesterol, non-dm, non-smoker, bp 110/50, resting pulse 52, no recreational drugs, both parents still alive in their 80s and several prior good experiences with anesthesia for common stuff like ear tubes as a kid, appy as a 20 yr old, etc

In our setting where we were the game in town in our neck of Dallas for cath/PTCA (pre-stent) it was too easy to see folks in the office and just perform the ETT.  Interestingly, we rarely did stress echo's at that time presumedly due to the fact that it was just too easy to send them down one floor in the hospital, stick them in for a same day cath, and then send them on their way the next day (after I would go by and listen to the groin to make sure that we hadn't created a dissection/aneurysm as a result of a new bruit) with the most definitive answer at that time.  One has to take into consideration that sand bags were kept in place for 12 hours I believe it was after sticking the femoral artery.  Over 3 1/2 years I think we ran across maybe 2-3 cases of Prinzmetal's angina.

[UGoLong]

1 hour ago, GetMeOuttaThisMess said:

In our setting where we were the game in town in our neck of Dallas for cath/PTCA (pre-stent) it was too easy to see folks in the office and just perform the ETT.  Interestingly, we rarely did stress echo's at that time presumedly due to the fact that it was just too easy to send them down one floor in the hospital, stick them in for a same day cath, and then send them on their way the next day (after I would go by and listen to the groin to make sure that we hadn't created a dissection/aneurysm as a result of a new bruit) with the most definitive answer at that time.  One has to take into consideration that sand bags were kept in place for 12 hours I believe it was after sticking the femoral artery.  Over 3 1/2 years I think we ran across maybe 2-3 cases of Prinzmetal's angina.

I'm hoping that was a while ago! We seldom go directly to an elective cath these days. Docs who do lots of caths with patients who seldom actually require intervention are looked at fairly closely these days. 

[GetMeOuttaThisMess]

20 minutes ago, UGoLong said:

I'm hoping that was a while ago! We seldom go directly to an elective cath these days. Docs who do lots of caths with patients who seldom actually require intervention are looked at fairly closely these days. 

They were all "at risk" patients since they were referred by their PCP's with CV risk factors.  We always made time to see a referral the same day.  You have to take into account that this was in the era of no PTCA w/o CVS standby (6% likelihood of emergent CVS during PTCA nationally at the time).  There were no small town hospitals doing these procedures due to the lack of this standby capability.  It was one of the things that drove me away; having a quiet day, about to walk out the door, and the cardiologist pages me to tell me to hang around another hour or two while we await the arrival of an out-of-town transfer just so I could do the H&P.  This practice was very highly respected and known regionally, if not nationally.  How many of us get to play with the groin of an Academy award winner who is snuck into the hospital on a Friday night to avoid knowledge by the media.  We were the first to have an EP specialist as well our own nuclear med radiologist to read scans.  We did have our share of hospital staff cardiologists who would troll the ED and suck up to staff IM docs so as to do some procedures.

[ventana]

19 hours ago, UGoLong said:

I hear what you're saying and I too do not see a reason for an in-hospital nuc stress test for the particular patient you described. And there is usually little reason for a stress test to clear an asymptomatic patient who already gets to 85% of the max age-predicted heart rate (220 - age) in his or her normal life. If they can't do that, then a stress test may be indicated for surgical clearance for the riskier surgeries. If a patient is not able to exercise (perhaps because their hip is getting replaced and it hurts too much to move), then a nuc can actually be an easier and faster test than the alternative: a dobutamine stress echo.

Screening guidelines to release someone from the ED by ruling out ACS are great and unclog your department without excessive risk. But it's not the same thing as what a cardiologist may decide to do on follow-up, nor should it be necessarily. That's why you have them follow up in the first place.

And let's not ride our own horses too high. I certainly don't endorse the behavior of everyone working in the same specialty that I do. On the other hand, for most of us, it's not an issue of "selling your morals" but of evaluating a given patient's risk.  I wouldn't assume everyone is trying to overbill. No one wants to be the one that blew off a symptom and didn't investigate further if that was called for. 

 

No high horse here.  Just a primary care PA that reads and believes that guidelines and EBM should be followed.  I have no beef with the appropriate test getting ordered. 

 

But no risk factors by the heart data at 51 male says new trop x 3 and no additional work up needed.  This is defensible EBM.  It is not me making rash decisions, it is following best guidelines.  Sometimes I think people forget interventions can be dangerous.  Just had a great PT get  second opinion in Cleavland.    They got her so pre Renal dehydrated (kept postponing cath due to conflicts is scheduling but kept her npo and on her normail diurects that she got in trouble.  Had zone 3 liver death likely from dehydration and now her abd is full of ascites.  They likely took a few years off her life cause they kept ordering more studies and forgot the basics.   Another cardio booboo.   

 

Point is we in primary care need not take a specialist word as gods as gods spoke word.  We need to talk to and listen to our patients and synthesize the information presented to us.  Don’t just go along, think.  Read. Talk to patient.  Team joint decisions. 

I hate to pick on cardio but it seems they are the biggest culprit right now. 

 

Just because we we can do something does not mean we should.  

[EMEDPA]

at the other end of the spectrum, I just set up an elderly pt with multiple risk factors for a nuc med study despite being sx free in the ED with nl trops and a stone cold nl ekg. it's all about risk stratification. pretty much as soon as this pt walked in the door they had a timi score of 3 and a heart score of 4-5(and would every day of the week). 

[GetMeOuttaThisMess]

12 minutes ago, ventana said:

No high horse here.  Just a primary care PA that reads and believes that guidelines and EBM should be followed.  I have no beef with the appropriate test getting ordered. 

 

But no risk factors by the heart data at 51 male says new trop x 3 and no additional work up needed.  This is defensible EBM.  It is not me making rash decisions, it is following best guidelines.  Sometimes I think people forget interventions can be dangerous.  Just had a great PT get  second opinion in Cleavland.    They got her so pre Renal dehydrated (kept postponing cath due to conflicts is scheduling but kept her npo and on her normail diurects that she got in trouble.  Had zone 3 liver death likely from dehydration and now her abd is full of ascites.  They likely took a few years off her life cause they kept ordering more studies and forgot the basics.   Another cardio booboo.   

 

Point is we in primary care need not take a specialist word as gods as gods spoke word.  We need to talk to and listen to our patients and synthesize the information presented to us.  Don’t just go along, think.  Read. Talk to patient.  Team joint decisions. 

I hate to pick on cardio but it seems they are the biggest culprit right now. 

 

Just because we we can do something does not mean we should.  

V, I hear you but allow me to throw a monkey wrench into the machinery.  About a decade back I attended a CA conference on a Saturday at one of our local major health network facilities (think Ebola in Dallas).  There was a urologist talking about PSA’s and CA and after he was done I asked him a simple question, “What do you do in your practice regarding PSA screening?”  He was taken aback for a moment and then told a story about a peer along the east coast of the U.S. who followed the guidelines and both he and a patient elected to defer on the PSA.  Next year, metastatic prostate CA in the same patient with a subsequent malpractice claim being filed..  The urologist’s defense was that the current speciality guidelines, as well as USPSTF recommended an informed discussion with the test being optional.  Where he lost his case was that in spite of the specialist following the guidelines, the standard of care in the community was antiquated and thus was not current.  Since the specialist didn’t follow the standard of care for his community he lost the malpractice case.  As a result of this story, he PSA’d everyone in spite of what he had just lectured about!

[UGoLong]

On 9/8/2018 at 12:05 PM, MT2PA said:

Also if they see your CASPA was verified in July and you are just submitting to them in September....it's pretty clear you're adding them after the fact (most people apply to all programs at once) and thus, a back up plan/hail mary app.  Even if they have a January deadline...it's a gamble.  

 

28 minutes ago, ventana said:

No high horse here.  Just a primary care PA that reads and believes that guidelines and EBM should be followed.  I have no beef with the appropriate test getting ordered. 

 

But no risk factors by the heart data at 51 male says new trop x 3 and no additional work up needed.  This is defensible EBM.  It is not me making rash decisions, it is following best guidelines.  Sometimes I think people forget interventions can be dangerous.  Just had a great PT get  second opinion in Cleavland.    They got her so pre Renal dehydrated (kept postponing cath due to conflicts is scheduling but kept her npo and on her normail diurects that she got in trouble.  Had zone 3 liver death likely from dehydration and now her abd is full of ascites.  They likely took a few years off her life cause they kept ordering more studies and forgot the basics.   Another cardio booboo.   

 

Point is we in primary care need not take a specialist word as gods as gods spoke word.  We need to talk to and listen to our patients and synthesize the information presented to us.  Don’t just go along, think.  Read. Talk to patient.  Team joint decisions. 

I hate to pick on cardio but it seems they are the biggest culprit right now. 

 

Just because we we can do something does not mean we should.  

 

I really don't want to defend a provider who leaps right to a cath and then screws up the patient. That's like doing an exploratory lap before a CT in a stable patient.

But there is a big difference between saying that you've done enough by the guidelines and ignoring that nagging voice in the back of your head that says "look farther, grasshopper." (Maybe the voice should add "But don't be a cowboy about it.")

guideline noun [ C ] us /ˈɡɑɪdˌlɑɪn/ › a piece of information that suggests how something should be done.

ACC/AHA Guidelines generally define themselves as follows:

Intended Use: Practice guidelines provide recommendations applicable to patients with or at risk of developing CVD. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations can have a global impact. Although guidelines may be used to inform regulatory or payer decisions, they are intended to improve patients’ quality of care and align with patients’ interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment. 

[ventana]

15 hours ago, UGoLong said:

 

 

I really don't want to defend a provider who leaps right to a cath and then screws up the patient. That's like doing an exploratory lap before a CT in a stable patient.

But there is a big difference between saying that you've done enough by the guidelines and ignoring that nagging voice in the back of your head that says "look farther, grasshopper." (Maybe the voice should add "But don't be a cowboy about it.")

guideline noun [ C ] us /ˈɡɑɪdˌlɑɪn/ › a piece of information that suggests how something should be done.

ACC/AHA Guidelines generally define themselves as follows:

Intended Use: Practice guidelines provide recommendations applicable to patients with or at risk of developing CVD. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations can have a global impact. Although guidelines may be used to inform regulatory or payer decisions, they are intended to improve patients’ quality of care and align with patients’ interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment. 

 

 

but if we "listen to that voice" with every single patient (they had note even seen the recent one - only a phone consult) are we just ignoring the guidelines??

 

I am pretty much done with this topic - I see rampant abuse of the system where specialists seem to have a carte Blanche to do what ever they want, and yet I am left filling out PA's for MRI's for everything..... or anything even slightly off formula ....  the system stinks...

[UGoLong]

I'm sick of this topic as well.

Until we're replaced by machines, we are here to apply some judgment, whether anyone else likes it or not. 

I do enjoy your posts, Ventana, and I hope your next workday goes better.

[ventana]

On 1/14/2019 at 3:23 PM, UGoLong said:

I'm sick of this topic as well.

Until we're replaced by machines, we are here to apply some judgment, whether anyone else likes it or not. 

I do enjoy your posts, Ventana, and I hope your next workday goes better.

you as well

 

hoping it gets better, if not I only have about 10-15 years left anyways....