The Future of Interventional Cardiology in 2024 and Beyond: Bridging the Health Equity Gap Through Policy Reform

As we stand on the cusp of 2024, the field of cardiology, particularly interventional and structural heart cardiology, is poised for transformative changes. The past few years have seen remarkable advancements in the treatment of heart disease, with minimally invasive procedures becoming more commonplace and the development of new devices and techniques that have proven to improve patient outcomes. However, despite these technological strides, disparities in cardiovascular care persist, underscoring the need for policy reform to ensure equitable access to these lifesaving advancements.

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It is no secret that interventional cardiology has made quantum leaps with the advent of transcatheter valve therapies. This started with transcatheter aortic valve replacement (TAVR), the minimally invasive treatment modality that has rapidly evolved into the standard of care for patients with aortic stenosis regardless of surgical risk. Similarly, other structural heart interventions, such as left atrial appendage closure (LAAC) to prevent stroke in patients with atrial fibrillation, have expanded treatment options for those previously considered untreatable. Yet, access to these advanced procedures is not uniform. Multiple studies have shown that socioeconomic status, geographic location, and yes…… race can influence the likelihood of a patient receiving these cutting-edge treatments.

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Adding to the advancements in the field, transcatheter mitral valve repair and replacement (TMVr and TMVR), have emerged as groundbreaking option for patients with mitral valve disease. These techniques, which includes devices such as the MitraClip (Abbott), Pascal (Edwards Lifesciences), Tendyne (Abbott), Intrepid (Medtronic), Neochord (NeoChord Inc), and Cardioband (Edwards Lifesciences), amongst a host of others under clinical investigation, are revolutionizing the management of mitral valve disease in real time.

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Of late, Tricuspid valve interventions have also seen significant innovation. Tricuspid regurgitation, once a neglected valvular disease, is now being addressed through novel transcatheter tricuspid valve repair and replacement techniques. These procedures are particularly important as they provide therapeutic options for a condition that has been historically difficult to manage medically and surgically.

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Both TMVR and transcatheter tricuspid valve interventions are poised to follow in the footsteps of TAVR, expanding the horizons of what can be achieved in structural heart disease treatment. As these technologies continue to evolve, they will likely become more widely adopted, offering hope to a larger cohort of patients with complex valvular heart diseases.

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However, the same disparities that affect access to TAVR, LAAC and in some cases PCI procedures also impact the availability of transcatheter mitral and tricuspid valve interventions. We should act now to ensure that the disparities in access and utilization of these new therapies do not mirror those of their predecessors. Policy reforms aimed at expanding coverage, increasing awareness, and ensuring equitable distribution of resources are essential to ensure that these innovative treatments can reach all segments of the population.

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TRIGGER WARNING: To the critics who roll their eyes at the sight of the word “disparities”, to those who downplay its significance, and those who merely pay lip service to the concept of health equity, it is my hope that 2024 brings to you an enlightened reality check. The evidence is irrefutable: inequity in healthcare is not just a moral failing; it's a blight on the very essence of our medical progress. While we celebrate the leaps in interventional and structural heart cardiology, we must not allow the bright glare of innovation to detract from the very dark shadow it casts on the underserved. The fight against disparities is not a hollow crusade for idealists; it is a pragmatic battle for the well-being of our entire society. Empty rhetoric on health equity without substantive action and policy change is akin to diagnosing a very curable cancer while withholding its very treatment. It is a disservice to the advancements we herald and, more importantly, a betrayal to the populations we've vowed to heal and protect.

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In 2024 and beyond, policy reform must be a catalyst for change with the focus being on several key areas to decrease disparities in interventional cardiology and by extension medical care. These include:

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1. Insurance Coverage Expansion with Geographic Practice Cost Index (GPCI) Adjustments: We must ensure that all insurance plans, including Medicaid, provide adequate coverage for advanced interventional and structural heart procedures. This would remove a significant barrier to care for underprivileged populations. However, beyond broadening insurance coverage, policies must ensure that GPCI adjustments do not inadvertently penalize providers in lower labor cost areas. Policies must be rewritten to account for the costly device intensive nature of these procedures as I discussed in a previous article.

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2. Thoughtful Hospital Resource Allocation: Subsidies and or tax breaks for hospitals providing critical cardiovascular services to underserved communities should be a focus, ensuring that the additional financial support makes up for the lower reimbursement rates in certain underserved geographic areas. This would make it financially viable for hospitals in these regions to maintain or expand their cardiology departments and services.

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3. Workforce Diversity: Policies should encourage and support the training and retention of a diverse cardiology workforce. This includes providing scholarships, loan forgiveness, and training programs for underrepresented minorities in medicine. A diverse workforce can improve patient-provider communication and trust, which is crucial for patient engagement and adherence to treatment plan.

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TRIGGER WARNING: I am at a loss as to why the term DIVERSITY is somehow now seen as something to shun and repudiate. I would encourage those who are so vehemently repulsed by the term DIVERSITY to strip their investment portfolios, 401k’s, and brokerage accounts of their DIVERSITY………. then we can have this discussion again in 4-5 years while analyzing their balance sheets. Maybe by then their views on DIVERSITY might change.

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4. Education and Outreach Programs with Localized Strategies: Tailoring community health programs to address local needs can ensure that resources are directed where they are most needed. Policies must address Social Determinants of Health (SDOH) by integrating social care into the healthcare system. There must be a focus on Intersectoral Collaboration between the healthcare sector and other sectors such as education, transportation, and housing which can lead to more comprehensive approaches to health and well-being, addressing the root causes of health disparities.

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4. Diversity in Clinical Trials with Geographic Representation: When I speak of diversity in clinical trials, I insist that geographic diversity must also be a priority. This means recruiting site Principal Investigators and clinical trial participants from a variety of practice settings, to ensure that the data reflects the efficacy of treatments across the entire spectrum of healthcare environments. I would even be tempted to suggest that the FDA stop approving new devices and therapies unless this criterion is met.

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5. Regulatory Support for New Technologies: Ensuring that regulatory pathways support the rapid approval and dissemination of new, safe, cost-effective technologies can help reduce disparities. This includes streamlining the process for technologies that have been shown to improve care in underserved populations. This can only be achieved with the aforementioned diversity in clinical trials with geographic representation.

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As we look to the future of cardiology in 2024, it is clear that we are innovating and developing the tools and knowledge to treat heart disease effectively. However, we must ensure that these advancements are accessible to all. Policy reform is the bridge that can close the gap between innovation and care delivery, to ensure that every patient, regardless of their zip code, race or socioeconomic status has access to the best possible cardiac care.

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Let us all be reminded that in the absence of health equity, advancements in medicine serve only a privileged few, and that is a status quo we can neither accept nor afford.

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Triston Smith MD FSCAI

12/29/23

Edwards Lifesciences Medtronic Cardiac and Vascular Abbott Boston Scientific Cardiology CommonSpirit Health Trinity Health System American College of Cardiology Society for Cardiovascular Angiography & Interventions European Society of Cardiology