Letter to the Editor Re: "Conversations in Cardiology: How Should Complex Procedures in Small Community Hospitals Be Managed?"

I read with interest the group discussion regarding the role of community hospitals in the performance of patent foramen ovale (PFO) closure (Conversations in Cardiology:  How Should Complex Procedures in Small Community Hospitals Be Managed?). I very much appreciated the fact that the Conversation was held at all, the thoughtful comments of Dr. Kern (who put himself in the shoes of the community hospital interventionalist), and especially the inclusion of Dr. Butman, as someone who actually comes from that world. This is a very relevant topic that is almost never addressed, yet has significant implications. Physicians working in community hospitals represent a true “silent majority” — who collectively care for more patients than those in large and/or academic medical centers (documented, for example, for valve surgeries), yet who are almost never represented on guideline-writing committees, editorial boards, society documents, etc.  
 

Recently this issue has become a bit more public, as hospital volume requirements for reimbursement for transcatheter aortic valve replacements (TAVRs) caused a stir in the structural heart disease community. Part of those volume requirements included the need for a hospital to perform a certain number of percutaneous coronary interventions (PCIs) per year – a requirement without one shred of data, which prevents some capable operators from performing TAVRs at their hospitals, and one that was muscled through by the power of the academic community. Sadly, this was without any “protection” or support for community hospital interventional cardiologists by Society for Cardiovascular Angiography and Interventions (SCAI), American College of Cardiology (ACC), or other professional societies who should be advocating for their clientele. 
 

To add salt to the wound, these professional societies subsequently came out with a document suggesting that PFO closures should be effectively banned from community hospitals, based upon scientifically unproven volume numbers, as discussed in this very interesting Conversations. Among other things, the impact of these stances is to limit access to care for this evidence-based, valuable procedure. Although I was able to start a PFO program at my community hospital, there are no other community hospitals within hundreds of miles with an active PFO program, effectively leaving patients in those communities without suitable access to this therapy (since there are no champions for the therapy in those communities). Academicians (including some involved in this Cath Lab Digest discussion) would say that those patients should be referred to academic or large hospitals, but that is a failure to acknowledge how the world actually works. 
 

Perhaps the most crucial issue is the lack of representation by members of community hospitals in the discourse of these issues, in the guidance documents, and policy decisions. This absence may be perceived as academic key opinion leaders protecting their domains by preventing the “silent majority” from being able to pursue some of these procedures – effectively quashing the competition. However, I am not so cynical. Rather, I think there is a lack of mindfulness to this as an issue. It seems only reasonable that there should be a seat at the table for some representatives of community hospitals in leadership meetings, in order to provide the perspective of those working in such environments. Yet that almost never happens. Since that is lacking, it is simply easier for those needs and perspectives to be ignored by the individuals who are currently participating in such leadership meetings. But the lack of appropriate representation is problematic and has the impact (among other things) of reducing access to care.   
 

It is in this context that I am appreciative of the conversation that was held, the support of Dr. Kern, and the inclusion and valued input of Dr. Butman. It was refreshing and important. Hopefully, the key opinion leaders in our professional societies will increase their mindfulness of this important issue and become more inclusive of representation from smaller community hospitals in creating guidelines, developing recommendations, and providing support.