“Care should always focus on improving quality and standards. We will only achieve this if we innovate.”
– Academy of Medical Royal Colleges, Evidence-Based Interventions, Proposed List 2
It is not uncommon to find that change is more than a bit uncomfortable. Especially when the change reaches directly into an area where our habits are deeply entrenched. We have seen this over the past year as many of the deeply ingrained habits of our work as healthcare professionals have undergone remarkable changes, largely driven by the global pandemic.
But during this same period, there have been notable innovations by some of the world's largest healthcare organizations that are not in response to COVID, but in pursuit of the goal of delivering better care to patients. Several examples can be seen in the work of groups playing integral roles in determining the best pathways for patients within the United Kingdom’s National Health Service.
The Academy of Medical Royal Colleges (AoMRC) released a list of 31 treatments or procedures for which they found a substantial change in “the evidence about their effectiveness or appropriateness”. For some on the list, the habit of ordering can easily be described as “deeply entrenched” for many cardiologists and general practitioners.
One example is diagnostic invasive coronary angiography (ICA) for patients with low risk, stable chest pain. The AoMRC recommends ICA should now be “offered only as a third-line investigation,” and a patient’s cardiac assessment should instead start with a non-invasive coronary CT angiogram (CTA). In cases where CTA-based anatomical information regarding coronary disease severity leaves uncertainty, a second-line test, such as a HeartFlow FFRCT Analysis, can assess lesion-specific physiology. By making ICA a third-line test, the large majority of the patients moving toward the cardiac cath lab would be heading there for planned intervention (stenting) to treat, rather than to diagnose, coronary artery disease.
In another example, the AoMRC finds that “exercise ECG has no role in the screening of asymptomatic and low risk patients for coronary heart disease.” This is the most common cardiac test in many countries, but this publication pushes us to understand that exercise ECG is currently being used far more often than is justified by the evidence. The AoRMC found no evidence that the use of exercise ECG improved patient reclassification, and in fact, on the contrary, they identified significant variation in the value of the test across sex, disease burden, age, and other factors which “limits its utility.”
Beyond the AoRMC, the UK’s National Institute for Health and Care Excellence (NICE) has also been pursuing innovation within the NHS. In April 2021, NICE renewed its support for the use of the HeartFlow FFRCT Analysis for patients in whom a front-line coronary CTA “has shown coronary artery disease of uncertain functional significance or is non-diagnostic.”
Such a clearly defined path is in sharp contrast to clinical practice seen in many parts of the world where a diverse array of stress test variations are used which are widely recognized to over- or undercall disease, resulting in patients being referred for unnecessary diagnostic ICA, or, even more concerning, being sent home with lurking undiagnosed coronary disease for which revascularization could provide better outcomes.
NICE carefully considered all of the literature published on the coronary CTA+HeartFlow pathway over the last three years, including some 80+ pieces of newly published clinical evidence. They found that HeartFlow reduces diagnostic ICA, speeds up time to a definitive treatment, and delivers significant per-patient cost savings of £391 ($545 USD) while preserving or even improving long-term outcomes.
So why is the UK taking such an aggressive stance to limit the use of some of cardiology’s most relied-upon tools, such as ICA and exercise stress testing? One answer from the AoMRC is that by eliminating or curtailing such use, clinicians will “free up valuable resources such as time” and thus “create headroom for innovation.”
This idea of “headroom for innovation” is striking. Anyone who has worked in a busy clinic seeing what may seem to be never-ending lists of patients can identify moments of feeling “there must be a better way, if only I had time to find it.” But we often do not have the luxury of time. Instead, we make countless real-time decisions every day for patients, often reaching for familiar tools out of habit or convenience. It is possible that familiarity with a test or tool makes us overly confident in its value, while blinding us to the time they take and the clinical and economic costs they exact.
It is only as we step back that we can find space to assess our habits and consider an alternative approach. If a shift from cardiology’s traditional diagnostic pathway toward a coronary CTA+HeartFlow pathway can improve the experiences and outcomes for many patients, while also reducing costs, it makes sense that many global healthcare providers believe that now is the time to “create headroom” for such innovations.
If we are aiming to improve, then finding the space required for innovation is key. It may be uncomfortable, but such change will enable us to truly deliver better care to our patients.