Circulation, Vol 84, 2213-2247, Copyright © 1991 by American Heart Association
CJ Pepine, HD Allen, TM Bashore, JA Brinker, LH Cohn, JC Dillon, LD Hillis, FJ Klocke, WW Parmley and TA Ports
It is evident that the practice of cardiac catheterization has undergone,
and continues to undergo, marked change. Most prominent are the recent very
rapid proliferation of catheterization laboratories in general and the
development of newer types of catheterization laboratory. No uniform
definitions exist for these newer laboratories, so meaningful communication
is difficult. The new settings are of particular concern because their
location, mobility, organization, and ownership raise questions about the
quality of patient care. Most difficult to address are the questions about
patient safety and physician conflict of interest. There are no objective
data in peer- reviewed literature to support the reported safety and cost
savings of these newer settings. Through deliberations, surveys,
interviews, and correspondence with the cardiology community embraced by
the ACC and the AHA, the task force generally found that in freestanding
catheterization laboratories, access to emergency hospitalization may be
delayed, and appropriate oversight may be lacking. Additionally,
opportunities for self-referral may be fostered and the perception of
commercialism and entrepreneurial excess in practice created. All of these
problems must be avoided. The growth and development of some freestanding
facilities, particularly the mobile laboratories, do not seem to have been
driven by an increased need in remote communities or for temporary support
but rather almost exclusively by a desire to capture market share.
Accordingly, a series of definitions, guidelines, and recommendations for
the laboratories as well as for patient selection has been developed. The
consensus was that a very restrictive and cautious attitude to the newer
settings is appropriate at this time. The justification for development or
expansion of cardiac catheterization services must be patient need.
Documentation of this need must be based on objective estimates of the
number of patients with known or suspected cardiac disease who meet
generally accepted indications for laboratory study. Concerns about the
lack of data from prospective clinical trials of patient safety in such a
group necessitate a very cautious attitude toward any new catheterization
services, in particular those without in-house cardiac surgical support. In
view of the lack of appropriately controlled safety and need data for
hospital-based, mobile, or freestanding laboratories operating without
on-site (accessible by gurney) cardiac surgery facilities, the task force
reaffirms the position that further development of these services cannot be
endorsed at this time. In addition, there is reason for major concern that
such proliferation in catheterization services may contribute to increasing
costs and troubling ethical questions.
ARTICLES
ACC/AHA guidelines for cardiac catheterization and cardiac catheterization laboratories. American College of Cardiology/American Heart Association Ad Hoc Task Force on Cardiac Catheterization
Office of Scientific Affairs, American Heart Association, Dallas, TX 75231.
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