For several programmes that are currently under development, the Netherlands Society of Cardiology (NVVC) is providing guidelines with respect to numbers of patients that should be treated to guarantee quality. A centre should perform at least 600 percutaneous coronary interventions (PCI) to qualify for a license. It would seem reasonable to limit the number of centres that perform these procedures in order to prevent an excessive capacity. In addition, for the interventionalist it is crucial to do sufficient cases in order to maintain and expand skills. Yet, if the exact number of procedures is to be leading for the maintenance of a license, this could easily result in a more liberal use of a potentially harmful intervention. Especially in the field of PCI we in the Netherlands are proud of the high number of functional measurements (FFR) preceding a PCI procedure, supported by studies such as DEFER and FAME. In order to provide a high quality of care and to become cost-effective it is crucial that PCI centres do not fall back to just eye-balling in order to decide whether a lesion should be treated or not. Deferring from PCI can be an excellent treatment, but requires informing the patient and referring cardiologist more intensively. Also the number of patients referred for bypass surgery will be further reduced despite the beneficial outcome of CABG.
However, if we were to consider dropping the quota criteria, how would we judge the quality? Thus far defining strict quality criteria appears to be an insurmountable task. For PCI it is currently possible to judge the patient’s risk by using a scoring system such as the Syntax score. In combination with a solid and complete complication registration this at least provides some insight on the general performance of a centre. So, quality and safety should be more important than numbers.
That numbers are crucial in decision-making was demonstrated recently when judging the paediatric cardiac surgery departments. A committee of well-respected cardiovascular specialists positioned numbers above quality in their advice to the Ministry of Health. Although it is obvious that concentration of care is cost-effective, no compromises should be made with respect to quality.
The next round of licensing will involve the centres that have applied for transcutaneous heart valve interventions. A total of 15 centres have applied for a license. As the therapy is still experimental it again seems wise to restrict the number of centres performing these interventions. Unfortunately, the NVVC proposed an arbitrary number of procedures (50) instead of focusing on quality and programme integration. For this novel intervention there are no international studies supporting the quota selected. Eventually, a solid programme could, after a few years, result in the performance of 50 cases or more annually.
Now it is up to the Health Inspection to determine criteria for quality. As the NVVC has special committees for quality it would be logical to implement a more careful process which will lead to improved quality and safety criteria supported by the members. Many transcutaneous heart valve interventions are currently being performed in catheterisation laboratories, which do not always reach the highest possible standards of hygiene and infection control. It is in the interest of the patient that a team of surgeons, imagers, cardiologists, paediatric cardiologists and other disciplines have an open discussion and together decide on and perform the selected treatment. Moreover, it is important to link permission to perform transcutaneous heart valve interventions to a license to invasively treat congenital heart defects. For instance, the pulmonary valve interventions must be performed in a licensed centre for congenital heart disease interventions. Of course, it is essential to record parameters as outcome, complications and quality of life.
Now it is up to the inspectors and hopefully they can look beyond the numbers and recognise quality, which is a difficult task for them. It would be desirable if the NVVC stays in the lead with respect to quality control for patient care in general, now and in the future.