MEDICAL NECESSITY FOR RIGHT HEART CATHETERIZATION

Because there are no definitive guidelines for performing right heartc atheterizations or controlled clinical trials demonstrating medical be nefit, ?he value and necessity of performing routine right heart cathe terizations for coronary artery disease have been questioned. This Tex as Medical Foundation Health Care Quality Improvement Program project was designed to ensure medical necessity and proper documentation of r ight heart catheterization when performed as part of a bilateral proce dure. Medicare claims data were used to identify Texas facilities wher e rates of bilateral catheterizations suggested that right heart cathe terizations were being performed routinely. Five facilities were found to have rates of bilateral procedures exceeding 70%. Suggested guidel ines for performing right heart catheterizations were prepared by the Texas Medical Association Committee on Cardiovascular Diseases. These guidelines together with the facility's data on its rate of right hear t catheterizations, were presented by the Texas Medical Foundation to the staff of each facility. They were asked to examine their individua l facility's procedures for ensuring medical necessity and to develop and implement process improvement plans. Medicare claims data were ana lyzed to determine the rates of bilateral catheterizations before and after the plans were instituted The statewide rate of bilateral proced ures decreased from 27.2% to 21.3% (p <0.005). Rate reductions for 4 f acilities implementing improvement plans were statistically significan t (p <0.001): al the Ist facility, the rate decreased from 74.3% to 25 .0%; at the 2nd, from 85.0% to 21.0%; at the 3rd, from 76.7% to 17.7%; and at the 4th facility, from 85.4% to 42.9%. The rate for the facili ty not implementing an improvement plan increased from 86.4% to 89.1%. Reductions in rates of bilateral procedures at the 4 facilities sugge st that many procedures previously performed were routine and not medi cally indicated. Presentation of data and practice guidelines to facil ities may have contributed to their ability to improve processes.