Interventional Cardiology ABIM Certification Not Strongly Linked to PCI Outcomes

In-hospital PCI outcomes do not differ substantially between physicians with interventional cardiology certification from the American Board of Internal Medicine (ABIM) and their noncertified colleagues, although mortality and emergency CABG risks are modestly increased after procedures performed by noncertified operators. The findings were published online September 18, 2015, ahead of print in Circulation.

The study “raises questions about the value of certification and what it can and can’t be used for,” study author Jeptha P. Curtis, MD, of Yale-New Haven Hospital (New Haven, CT), told TCTMD in a telephone interview. “It seems to me that what may distinguish those who are and are not certified is their ability to take a standardized test. We may just be weeding out people who aren’t good at standardized tests as opposed to people who aren’t good in the cath lab.”

Using data from the National Cardiovascular Data Registry (NCDR) CathPCI Registry and the ABIM, Dr. Curtis and colleagues examined outcomes of 510,708 PCIs performed by 5,175 physicians in 2010. Each included physician did at least 10 procedures that year.

Most operators (70.8%) held current interventional cardiology certification at the beginning of the year. Noncertified physicians included those deemed “grandparents” who finished fellowship before 1999 and never held interventional cardiology certification with the ABIM (n = 1,044) as well as those who finished fellowship during or after 1999 and were never certified (n = 149) and those who let their certifications lapse (n = 316).

More than three-quarters of procedures (78.2%) were performed by certified physicians, who had a higher average PCI volume and were more likely to do at least 50 procedures in 2010. Certified operators were more likely to treat patients with heart failure, STEMI, and ACS and less likely to treat patients undergoing elective procedures or who had a history of PCI. Among procedures performed in non-ACS patients for which appropriateness could be determined, certified physicians had slightly higher rates of PCIs that were inappropriate (13.1% vs 11.8%; P = .002) and appropriate (24.7% vs 23.1%; P = .038).

Before accounting for differences in patient characteristics and PCI volume, in-hospital outcomes did not differ between certified and noncertified operators. After adjustment, however, the odds of mortality or emergency CABG were higher in the noncertified group (table 1).

According to estimates from recycled predictions, absolute increases in mortality and emergency CABG were 0.08% (1 additional death for every 1,250 patients) and 0.03% (1 additional bypass for every 3,333 patients), respectively. “The overall event rates were low, and the clinical significance of these differences may be modest,” the authors say.

Competency Best Assessed During Training

A clinical competence statement from the American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions strongly recommends that physicians performing PCIs hold active ABIM certification in interventional cardiology, but no prior studies have examined whether such certification is associated with improved outcomes.

“Critically assessing the certification process is essential, as physicians have challenged the certification process in both the lay and research press, citing time and financial pressures as well as a perceived lack of value of the process,” Dr. Curtis and colleagues write.

“We need to invest our time, energy, and money wisely, and I think we really have to see that there’s a value to any certification or other requirement that we’re using to categorize physicians,” Dr. Curtis said.

He and his colleagues cite multiple possible reasons for the lack of a strong relationship between interventional cardiology certification and PCI outcomes:

• PCI is safer and more reliable today than in the past
• Heterogeneity exists among noncertified physicians in that some did and others did not complete an accredited fellowship in interventional cardiology
• Factors captured by the ABIM certification process (eg, knowledge, test-taking skills) may not be the same as those needed to assess physicians who perform PCI (eg, manual dexterity, decision-making ability, and skill in managing complications)

The value of certification could be strengthened through mentorship or ongoing coaching for physicians who have completed fellowships, but the best way to evaluate the competency of operators is through detailed assessments during training, Dr. Curtis advised.

“When we’re evaluating fellows during their clinical rotations, we have the ability to determine whether or not a physician has the skills to be a good interventional cardiologist,” he said. “I think that really those reviews of trainees represent the best opportunity we have to categorize physicians into those who are going to be good operators or bad operators.”

‘Question Remains Unanswered’

In an accompanying editorial, Spencer B. King, III, MD, of Emory University School of Medicine (Atlanta, GA), acknowledges the “heroic effort” of the study authors to explore the association between certification and PCI outcomes, but he adds that “the question remains unanswered.”

The researchers were unable to account for coronary anatomy, degree and distribution of disease, residual Syntax score, or outcomes after hospital discharge, Dr. King points out. In addition, MI was not assessed.

He also says that the use of hospital mortality as the primary quality metric is problematic. Nevertheless, “the findings here of 1 excess death per 1,250 patients treated by physicians without boards would translate to about 10 excess deaths per year in my city, [which is] not an insignificant clinical outcome,” he says.

Dr. King disagrees with the study authors’ assertion that the certification exam cannot capture important characteristics like the ability to make good decisions under stress and to treat procedural complications.

“During my tenure as chairman of the interventional cardiology examination, many of the most discriminating questions were about recognition of angiographic anatomy and anticipation of best approaches to performance and solutions to complications,” he says. “This is practical knowledge that comes from extensive experience.”

Study Does Not Address Ongoing MOC Debate

Both the study authors and Dr. King point out that the current study cannot address the ongoing debate surrounding recertification or maintenance of certification (MOC). “These 2 issues are, in fact, the ones that have generated the most questions, not the initial certification,” Dr. King notes. “Whether taking an entry exam again or participating in MOC activities enhances the goal of maintaining competence for the continuously engaged practitioner is under scrutiny and is not addressed in the current study.”

“Our study adds additional fuel to the fire of what’s already a very contentious debate,” Dr. Curtis said.

Interventional cardiology is now a field of subspecialties, Dr. King concludes. “How will interventional cardiologists assure their peers and the public that they have ‘the clinical judgment, skills and attributes essential for the delivery of excellent patient care’ in these specialized areas? This will require active engagement of the professional societies, academic training programs, and testing organizations.”

Sources: 
1. Fiorilli PN, Minges KE, Herrin J, et al. Association of physician certification in interventional cardiology with in-hospital outcomes of percutaneous coronary intervention. Circulation. 2015;Epub ahead of print.
2. King SB III. To be certified or not to be: is that the question [editorial]? Circulation. 2015;Epub ahead of print.

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