We have read the letter by Fernández-Rodríguez et al1 about decision-making in cardiology patients and we would like to congratulate the authors on their original analysis. The choice of type of treatment to be applied is a key moment, and the decision-making process, with consultation between clinician and surgeon, begins with the coronary angiography. The importance of this process is reflected in the 2014 Myocardial Revascularization Guidelines of the European Society of Cardiology,2 in which the creation of a Heart-Team is a class I recommendation with level of evidence C.
There are several factors that influence the decision and the study by Fernández-Rodríguez et al1 reflects a variable not considered until now, related to group behavior in decision making. Considerations on the incidence of coronary artery disease notwithstanding, Spain is the European country with the lowest rate of coronary artery surgery (17.7 cases/100 000, whereas countries such as Germany, Denmark, Belgium, and Turkey have as many as 67-68 cases/100 000), a fact we believe is worthy of reflection.3 The factor indicated by Fernández-Rodríguez et al1 can be considered unmodifiable, but there are other modifiable factors that could reduce these differences. In our opinion, although the Heart-Team does not have any administrative function, it has sovereignty on clinical decision and should analyze the situation of the cardiovascular treatment in its catchment area and look for potential improvements. In more flexible models, such as in New York in the United States,4 the process is strictly controlled by the clinic and failure to apply the guidelines has legal consequences. The clinic itself chooses the interventionist or surgeon in agreement with the patient, whose insurance pays for the procedure even if the chosen operator resides outside the patient's hometown or state. In addition, the New York model includes an audit of outcomes weighted according to the complexities of the case by external auditors who report to the state of New York. The risk for each patient is calculated by logistic regression according to their clinical characteristics, and errors in the data provided to the auditors result in hefty sanctions for the center. With this model, mortality decreased by 41% between 1989 and 1992, and from 1992 onwards, data have been available on the Internet by operator and center, such that the patient has access to them. Finally, there is no waiting list as the patients themselves will penalize the center by going to another.
In Spain, our model has highly qualified operators and up-to-date infrastructure, but there are several factors that could be modified, at least partially, and these factors are, in our opinion, what has led to the current situation. The first defect is that patients are forced to attend a given center, without the option of choosing the clinical cardiologist or operator, and these professionals are paid the same regardless of their ability, activity, and results. Second, the lack of transparency in the waiting lists for surgery means that clinicians and interventionists are distrustful of surgery when a prolonged wait may be detrimental to the patient.5 Third, given a lack of infrastructure, audits, in addition to being limited in number, have been criticized for being based on administrative information and not on the clinical characteristics of the patients.6 This model failed in New York and led to a suspension of audits until the current model based on individual risk was implemented.4 Finally, a reduced presence of the clinician in the decision-making process, in combination with loss of confidence in surgery and a lack of consequences if guidelines are not applied, means that the decision power of the interventionist is high and that patients who arrive in the catheterization laboratory are highly selected.
Although a complete solution to these problems would appear a utopic ideal, we believe it is possible to try more flexible models, as the structure is, to a large extent, responsible for the current situation.