Patient care and physician conflicts of interests

Authors: Sanjeev Saksena

Publish Date: 2015/02/10

Volume: 42, Issue: 1, Pages: 1-4

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Abstract

The start of a new year always gives us another chance to reflect on what has been achieved and what needs to be still done In 2014 the Journal has prospered and grown in scope and submissions This has been a particularly successful year in bringing more participation in the direction of the Journal and broadening its leadership We have continued to define a clearer vision and found new avenues to bring better and more diverse science to our readership The online availability of the Journal has become more facile New members have joined the editorial leadership and a series of new initiatives have taken root Their fruits will be apparent in due courseIt is becoming a tradition now for the inaugural editorial each year to address a complex often vexing and certainly challenging issue This year I have chosen to turn to the issues of physician/investigator conflicts of interest as new dimensions continue to evolve These new developments challenge the daily performance of clinical care and in turn impact the clinical investigation environment This issue first came to my notice just as I commenced my career as an independent investigator in 1980 A prescient editorial was published that year by Arnold Relman entitled the “medicalindustrial complex” in which he famously noted “the most important healthcare development of the day is the recent relatively unheralded rise of a huge new industry that supplies healthcare services for profit” This commentary catapulted this issue into the dead center of the health care debate where it remains till today 1 Clinical and interventional electrophysiology as a medical discipline was but a twinkle in some of our eyes at that timeRelman went on to comment “in this medical market physicians must act as discerning purchasing agents for their patients and therefore should have no conflicting financial interests Closer attention from the public and the profession and careful study are necessary to ensure that the ‘medicalindustrial complex’ puts the interests of the public before those of its stockholders” Fifteen years later I recall participation in another informal conversation about the health care industry with leaders in clinical electrophysiology Now representing the government relations arm of the then North American Society of Pacing and Electrophysiology and government relations editor for PACE I offhandedly observed to my colleagues “that health care cannot just be a business” I was reminded read chided that I may have missed the fact the health care industry is just that a business I recall responding that it could not be run in the longterm as a business solely on financial principles Almost a decade later all of us revisited this issue in the era of stalled expansion of managed care and the telling rejection of such draconian management of health care access  by the American patientYet 35 years later there is little doubt of the continuing relevance of the Relman commentary Financial incentives among others that can influence health care professional performance in their duties have been widely identified Codes of conduct have been established by professional societies and in the law While too many to enumerate here these issues now encompass all aspects of a medical professional’s work and life experience Starting in the 1980s with the regulation of industry support of continuing medical education pharmacy committees at hospital with serious bottom line input from hospital management research grants medical consulting lecture honoraria and litigation consultation the list continues to evolve Importantly transparency in these relationships has been adopted in most spheres of health care professionalindustry interactionsWhile the relationship with the for profit medical industry has been the focus of this issue physician incentive programs directed at monitoring and channeling direct clinical care are now evolving growing new heads of this Hydra with each passing year In 2015 a new development has taken firm root financial incentives for “efficient” medical care and the use of electronic medical records These incentives are being provided by notforprofit governmental agencies but are often given to for profit hospitals physician practice organizations and even individual physicians Going well beyond the Relman doctrine in the age of electronic medical records and “bigdata” this introduces new “incentives” that can change physician behavior driven by personal and institutional financial considerations and engender patient care concerns For the practicing electrophysiologist these have special concerns that I will highlight here Key to this approach of behavior modification is the availability of necessary data from electronic medical records To achieve this end physicians are financially penalized now for not maintaining and reporting data from electronic medical records and are financially rewarded for doing soIndividual physician inpatient clinical activity at one hospital during a defined analysis period is shown using a dashboard format The gauge needle provides guidance as to how the individual physician data compare to a comparator standard Only a few selected fields are shown to provide a conceptual rendering of this data report Green reflects a favorable performance while orange or red exceed the comparator standardFor clinical electrophysiologists who provide a tertiary level of care this poses special dilemmas Arrhythmia management can be necessary emergently or subacutely with timing of antiarrhythmic interventional procedures being dependent on staging in an overall cardiovascular treatment algorithm All too often this occurs later in a hospitalization For more elective interventions comorbid conditions can intrude and require careful management In either instance the pressure to avoid prolonging hospital stay is significant and when coupled with financial incentives can be a particularly toxic combination impacting optimal patient care Among those that would speak favorably about targeted incentives to impact inpatient health care costs the rejoinder would include the use of quality of care metrices to balance a rush to patient discharge And why should this issue be particularly important for one subspeciality as it can be a generic concern And is it truly a new “conflict of interest”While clinical electrophysiologists may not be totally unique they have often served as an early warning system for specialty care as those involved in such matters on behalf of this specialty have experienced This may be another such instance While gaming the metrices in use is entirely feasible and practiced to a larger degree than recognized this does not serve the needs of better patient care One cogent example can speak to this point Recently Pathak and coworkers reported the results of the ARRESTAF study 2 They noted that the longterm outcome of catheter ablation in atrial fibrillation is seriously impacted by effectiveness of comorbidity management Excellent control of risk factors such as diabetes hypertension sleep apnea smoking alcohol excess and other conditions reduced the need for repeated ablative procedures during longerterm followup While the control group was not randomized and comprised patients refusing risk factor management participation in a dedicated clinic the study nevertheless showed gains in both patient care and by inference health care costs in the longterm by initiating such a program Such programs require coordination of care best done in the hospital setting to initiate the patient into longitudinal wellmanaged health care in the outpatient setting Current shortterm rewards for “efficient” patient care fail to recognize the reality of longerterm care for patients with increasing comorbidities that underpin arrhythmia surges and are an essential component of management In this commentator’s opinion it is such care should be funded and “rewarded” The arrhythmia community needs to strive to highlight the coordination needed in the health care team for optimal care and the time needed to achieve it rather than focus on volume and rapid patient processing In doing this the electrophysiology community will again take a leadership role in highlighting the particular needs for diseasedriven specialty care

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