Are There Differences in PCI Outcomes Between Certified and Non-Certified Physicians?

Physicians who received interventional cardiology (ICARD) certification through the American Board of Internal Medicine had similar outcomes following percutaneous coronary intervention (PCI) as physicians without certification, according to a study published Sept. 18 in Circulation. This study is the first to evaluate the impact of interventional certification on patient outcomes in the 15 years since certification began.

Using data from the ACC’s CathPCI Registry, researchers assessed records from 510,708 patients who had undergone PCI performed by 5,175 physicians in 2010. Researchers looked at all-cause in-hospital mortality and bleeding complications as primary endpoints and emergency coronary artery bypass grafting (CABG) and vascular complications requiring therapy as secondary endpoints. 

A total of 3,666 (70.8 percent) physicians had ICARD certification, and they performed the majority of procedures (399,153, or 78.2 percent). In addition, a higher proportion of certified physicians performed at least 50 procedures compared to non-certified physicians (77.6 percent vs. 55.6 percent). The ICARD group also had a slightly higher proportion of patients with heart failure, history of myocardial infarction, and acute coronary syndrome, while non-certified physicians had a higher proportion of patients with prior PCI and undergoing elective PCI.

After adjusting for patient characteristics, including age, gender, race, and comorbidities, and PCI volume, the study found that the risks of mortality and emergency CABG were higher among non-ICARD certified physicians than among those with certification. The absolute increase in mortality was 0.08 percent, which translates to one additional death for every 1,250 patients. There was one additional emergency CABG for every 3,333 patients treated by non-certified physicians.   

“Our results demonstrate that the outcomes of patients undergoing PCI are similar regardless of the interventional certification status of the performing physician,” says Paul N. Fiorilli, MD, the study’s lead author and a cardiologist in the department of internal medicine at the Hospital of the University of Pennsylvania. “The study demonstrates that the certification process as it currently stands can be improved so that it can better discriminate the procedural skills necessary to safely and effectively perform PCI.”

In an accompanying editorial, Spencer B. King, III, MD, MACC, from Emory University School of Medicine in Atlanta, explains that he does not believe that that the study answers the question of whether there is an association between board certification and clinical outcomes. He points out that the study does not account for the coronary anatomy and degree and distribution of disease. He also notes that “the quality of coronary interventions cannot be assured by a low mortality rate.”

In addition, King questions why the study did not look at the value of recertification or maintenance of competence, especially since those two issues have generated the most questions. “Whether taking an entry exam again or participating in maintenance of competence activities enhances the goal of maintaining competence for the continuously engaged practitioner is under scrutiny and is not addressed in the current study,” he writes.

Finally, King does not believe that these findings support the authors’ conclusion that subspecialty certifications need to be enhanced. Rather, he sees the approved training programs and certifying exams as a way to identify those who have mastered an adequate level of knowledge, judgment and skills to be considered qualified practitioners.

He speculates that the certification process has succeeded in winnowing out those physicians more suited to other areas – an important result of the process. He explains that, “interventional cardiology has evolved, and training and certification of competence must evolve as well. See one, do one, teach one – the formula for early training programs – is for the history books.”

"ABIM has recently reported that they are undergoing self-evaluation and transforming the certification process to improve relevance and effectiveness,” said ACC President Kim Allan Williams, MD, FACC. “This publication appears to indicate that this process of transforming certification is quite timely.”

Keywords: Acute Coronary Syndrome, Certification, Comorbidity, Coronary Artery Bypass, Heart Failure, Hospital Mortality, Myocardial Infarction, Percutaneous Coronary Intervention, National Cardiovascular Data Registries, CathPCI Registry

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