Is it just the money?

I read with interest the study of Duffy et al. [1] assessing intermediate coronary stenoses with coronary flow velocity reserve and stress echocardiography. As I am continually interested in the progress of integrating coronary physiology into clinical practice, I would like to question the question asked and answered by Klein and Schaer [2]: “If invasive functional testing is so great, why are we not doing it routinely?” The abundant data demonstrating the strong correlation of physiologic measurements to ischemic stress testing is reiterated by both Duffy et al. [1] and Klein and Schaer [2]. In fact, the gentlemen from Chicago [2] astutely and I believe accurately examined the issues and, like others, found that functional testing does have evident clinical value for patient decisions. Nonetheless, they conclude that physician reimbursement is the reason that these techniques “will never become an established tool in clinical decision-making” [2]. Interestingly, the same position was recently espoused by Sabera-Gomes [3] of Portugal, who wrote in the European Heart Journal that the functional coronary lesion assessments “make sense but I just don’t do them,” delicately leaving the exact reasons unstated. Is it just the money? If we were in ordinary business, our principal goal would justifiably be money. But in the business of medicine, our principal goal is health care, money being a far secondary concern. Naı̈veté aside, it should be disturbing to physicians and especially interventionalists that money is a major, if not the predominant, driving force for the use of new techniques. The additional physician time (usually 30 min) of employing functional testing has also been cited as a negative factor. Physicians should certainly recognize that time spent in objectively assessing a stenoses clinically outweighs the shortcut of a best guess as to whether the procedure should or should not be performed without appropriate data. At the risk of representing a biased view, I remind the readers that the measurement of in-laboratory coronary physiology is no longer complex, does confirm a therapeutic approach supported by data, provides independent and complementary data to both angiography and IVUS, and has substantiated prognostic value. Although small, procedural reimbursement in this country is available for the physician. The remaining expense of the sensor guidewires is more than offset by the human expense of an unnecessary stent and/or bypass surgery. The extensive and well-collected correlative data, added to by those of Duffy et al. [1], support the use of physiologic tools where appropriate. Money, i.e., physician reimbursement, and time should not drive the dictum “when in doubt, dilate.” A proper appreciation of the patient’s needs above all else should convert it to “when in doubt, measure and decide.” Despite the financial implications of their concluding remarks, Klein and Schaer [2] know that in their own practice they always try to do the right thing for their patients.