Certification for interventional cardiologists does not lead to uniformly improved outcomes

Interventional cardiologists who received certification from the American Board of Internal Medicine (ABIM) did not have better outcomes after PCI with regards to the risks of bleeding and vascular complications compared with those who were not certified.

However, multivariable analyses found the risks of mortality and emergency CABG were significantly higher in patients treated by non-certified physicians. The increases in mortality and emergency CABG were 0.08 percent and 0.03 percent higher in the non-certified group.

Lead researcher Paul N. Fiorilli, MD, of the University of Pennsylvania, and colleagues published their findings online in Circulation on Sept. 18.

“My bottom line, take home message for this is that certification in and of itself isn’t a really strong discriminator of good operators and bad operators,” study author Jeptha P. Curtis, MD, an ABIM-certified interventional cardiologist at Yale-New Haven hospital in Connecticut, told Cardiovascular Business. “While having certification is an indicator that you’ve gone through a specific training process and that you have achieved certain metrics, that information may not necessarily translate into uniformly better outcomes in the cath lab.”

In this study, the researchers searched the ABIM database to obtain physician certification information and gathered patient outcomes data from the National Cardiovascular Data Registry’s CathPCI registry. They identified 5,175 physicians who performed at least 10 PCIs in 2010 and included a total of 510,781 PCIs.

Of the interventional cardiologists, 70.8 percent were certified and 29.2 percent were not certified. Certified physicians performed an average of 111.8 PCIs in 2010 compared with 75.8 PCIs for non-certified physicians.

The mean age was 49.9 for all interventional cardiologists, including 54.8 for noncertified physicians and 48 for certified physicians. Only 3.2 percent of the physicians were female.

ABIM first offered certification for interventional cardiologists in 1999. Now, physicians performing PCI should be certified, according to a clinical competence PCI statement from the American College of Cardiology Foundation, the American Heart Association and the Society for Cardiovascular Angiography and Interventions.

In August, ABIM announced that physicians who meet program requirements would not lose their certification if they fail to enroll in ABIM’s maintenance of certification program.

“Our study fits into what is an increasingly contentious argument within medicine about what exactly the role of certification and specifically maintenance of certification has in clinical practice today,” Curtis said. “There have been a lot of questions raised about changes that have been made to the maintenance of certification program at ABIM. Our study doesn’t directly address some of the questions that have been raised, but it does to a certain extent put fuel in the fire of that argument saying that the outcomes of physicians who are and aren’t certified are really quite comparable.”

Interventional cardiologists who were certified had a higher proportion of patients with heart failure (11.8 percent vs. 11.1 percent), ST-segment elevation MI (16.3 percent vs. 15.5 percent) and acute coronary syndrome (70.2 percent vs. 68 percent), while those who were not certified had a higher proportion of prior PCI (41.7 percent vs. 40.3 percent) and undergoing elective PCI (48.9 percent vs. 44.2 percent).

Multivariable analyses found the risk of death was significantly higher in patients treated by non-certified interventional cardiologists who completed their fellowship before 1999. The risk of emergency CABG was significantly higher in patients treated by non-certified physicians regardless of when they finished their fellowship.

Although the risk of death and emergency CABG were higher in the non-certified group, Curtis said an extra 800 to 1,500 procedures performed by a non-certified physician to have one more death or emergency CABG compared with procedures performed by certified physicians.

“You can look at that and say, ‘That’s meaningful. We need to promote and have certification of all physicians who are performing these procedures,’” he said. “On the other hand, you can say, ‘That’s clinically modest and probably could be explained by a number of other factors.’”