Q and A article

Q&A with Dr. James McCabe: Interventional Cardiology and Public Reporting

James McCabe, M.D., an interventional cardiologist, has practiced for five years at the University of Washington in Seattle and acted as the cath lab director there for the past three years. He earned his M.D. from Yale University, continuing training through an internal medicine residency and general cardiology fellowship at the University of California, San Francisco. He then completed an interventional cardiology fellowship and an advanced interventional fellowship in structural and peripheral interventions at Brigham and Women's Hospital/Harvard Medical School.

Dr. McCabe sits on the management committee for the Cardiovascular Outcomes Assessment Program (COAP) and is the former head of its Percutaneous Coronary Intervention (PCI) Analytics and Reporting Subcommittee. In his clinical practice, he focuses on treating complex coronary and valvular heart disease with catheter-based therapies. Dr. McCabe’s research interests center on quality and performance metrics for cardiovascular procedures and how public reporting influences outcomes.

What brought you to interventional cardiology?

I became interested in the field during training after seeing what was being done to help people. What I saw then almost seems quaint compared to what we can do for patients today.

I feel profoundly lucky to be an interventional cardiologist. The technological developments are quite fast-paced, and the opportunities to care for critically ill patients grow so much every year. We can make fundamental improvements in the quality and duration of patients’ lives in ways that were almost unimaginable five or ten years ago.

Noting the advent of transcatheter aortic valve replacement (TAVR) and the Placement of Aortic Transcatheter Valves (PARTNER) trial, what was it like to enter the field at such a disruptive time?

The TAVR trials like PARTNER have been game changers for a huge number of patients. This past year marks the first in the United States when more patients received TAVRs than surgical valve replacements, demonstrating the quick adoption of this new technology. It’s been an amazing time for patients—people are being afforded opportunities that they simply weren’t before.

Professionally, it’s an interesting time. We’re producing young physicians who have a lot of novel, valuable experience. However, they’re going out into new jobs where they have lack political capital while they’re finding their way. That was an interesting process for me to navigate. It’s probably even a more complicated process for today’s trainees. So, this technological disruption relates both to patients and our careers.

Increasingly, interventional cardiologists are working collaboratively with radiology. How do you facilitate communication between departments? 

Newer advances that allow for more minimally invasive but more effective therapies largely rely on multidisciplinary teams. Silos of knowledge don’t leverage the full capabilities of any medical institution. 

In the older model of surgical valve replacement, one surgeon could open the chest, look at the aortic valve, put in a sizing device, and pop in a new valve after removing the old one. In the new model of TAVR, we need to size the valve in a less-invasive manner. That’s where radiology expertise comes into play. One of the real leaps forward in effective outcomes for TAVR was when people realized that computed tomography (CT) and perhaps 3D transesophageal echocardiography (TEE) could provide more precise measurements.

Working with radiology is key and so is working with surgery, geriatrics, and cardiac rehab. There’s a broader movement afoot to organize teams of specialists around disease states.

Percutaneous coronary interventions (PCIs) have become more complex—and less common. What are the contributing factors to that?

A lot of changes have been leading to that, probably for the better. One is that appropriate-use criteria have been aggressively espoused: we shouldn’t be treating the simplest coronary artery blockages when the perceived benefit to patients isn’t there.

It took some time for the data to establish where that perceived benefit to patients is. Now, we have a better understanding. Treatment is being deferred at earlier stages, and therefore, fewer procedures happen. In that context, the people who do come for coronary artery intervention come later in the process when the illness is more severe. That means patients are also showing up later in life. They might have more trouble with other organ systems. The cases are more complicated, and the presentations tend to be more acute, more on the spectrum of heart attacks. This all dovetails into challenging scenarios that require improved skills and technology—things like intravascular ultrasound-guided implantation and robotic-assisted PCI—as well as better communication with our imaging and surgical colleagues.

Aside from aortic stenosis, are there other cardiac conditions that can be effectively treated with transcatheter therapy? What does the future of the field hold? 

There are areas being treated reasonably well, such as acute myocardial infarction (MI). Mortality rates from acute MIs have dropped precipitously with the advent of aggressive invasive therapies like stenting or coronary artery bypass therapy. A great deal of investment in that condition over the last ten or fifteen years has borne tremendous fruit: people are doing better.

I think the next big growth area is in cardiogenic shock and ischemic cardiomyopathy. Cardiogenic shock, a sequela of acute MI, remains difficult to treat and continues to have high inpatient mortality rates on the order of 40–50%. Ischemic cardiomyopathy grows as a chronic condition among patients who may have had an acute MI ten years ago. These two areas are ripe for further innovation and transcatheter therapies, as they’re more common because of the increased efficacy of treating people with the initial MI who may not have made it to this point in their lives otherwise.

The Affordable Care Act (ACA) has led to an increased focus on healthcare quality and value-based care. How has this impacted your practice?

The politics of healthcare is Byzantine. What happens on the news and what makes headlines in the papers doesn’t trickle down to the clinic or cath lab immediately. Hopefully it never erodes the relationships between the people having a discussion about treatment options.

That said, you need to keep the lights on and bills paid. Increasingly, physicians are asked to be stewards of healthcare spending. That’s a challenging place to be. Of course, there are scenarios where it works. But the cost containment can also become synonymous with withholding care on some level. That’s a more difficult issue that needs to be addressed on public health and ethical levels. For the patients who put their trust in me, I don’t want to bring those politics into the cath lab or clinic room because they’re better addressed elsewhere.

How has the growing focus on public reporting affected clinical outcomes?

In my mind, public reporting is a relatively controversial topic. There's the obvious intuitive benefit: it increases transparency, which fosters the adoption of best practices. It’s a mechanism for the Hawthorne effect, how something changes due to a someone’s awareness of being observed.

Theoretically, public reporting adds some layer of consumerism to medical care. Patients can shop where they’d like their care to be performed. However, a lot is unproven. What we have demonstrated fairly convincingly is that, unfortunately, there are consequences including selection bias against treating the highest-risk patients.

As an illustration—if I was going to give you a pop quiz in the middle of the night, and I said, “By the way, I’m going to tell everyone your score. You can take either a simple arithmetic test or an advanced calculus test,” most of us would pick the simple arithmetic test. We want those around us to know we get a perfect score.

There’s pretty solid data suggesting one of the unintended consequences of public reporting is this risk aversion. Physicians or hospital groups worry about their public perception and may unconsciously shy away from the most needy, the most difficult patients. The people who stand the most to gain from transcatheter therapies are also the patients who have the worst overall mortality rates: it’s the treatment-risk paradox.

Public reporting does have its benefits, which have been demonstrated in publications over the years. The story just isn’t finished yet. We need to follow a reporting process that makes sure our most high-risk patients get the treatment they need.

What would you like people to know about the practice of interventional cardiology?

Interventional cardiology is a wonderful field, and I’m blessed to be in it. It does come at great sacrifice: we have long hours and miss important personal obligations. There’s a growing suspicion that Western physicians are in bed with companies, that they’re just in it for the money. Nobody’s rushing in at 3:00 AM because they’re seeing dollar signs. The field is really driven by people who are passionate about doing right by the folks who come to see them and trying to figure out how to improve public health in the communities where they live.

Overall, the technological advances in the field have come at a breathtaking pace, and the opportunities are amazing. It’s incredible to understand where someone’s limitations are, where they want to be—and then offer them something that may be able to really improve their quality of life.