Study Finds Both Underutilization and Overutilization of Coronary Revascularization for CAD Patients in Canada

A study published on Oct. 10 in the Journal of the American College of Cardiology found that substantial underutilization and overutilization of coronary revascularization exists in clinical practice in Ontario, Canada.

Underutilization is associated with significantly increased risks of adverse outcomes in patients with appropriate indications.

Using the ACC's appropriate use criteria (AUC) for coronary revascularization, the study looked at 1,628 patients with stable coronary artery disease (CAD) between April 2006 and March 2007, and found that percutaneous coronary intervention (PCI) or coronary artery bypass grafting CABG was only performed in 69 percent of patients who had an appropriate indication for coronary revascularization. Coronary revascularization was associated with a lower adjusted hazard of death or acute coronary syndrome (ACS) (hazard ratio [HR]: 0.61; 95 percent confidence interval [CI]: 0.42 to 0.88) at three years compared with medical therapy in appropriate patients. Results also showed that among the patients who received coronary revascularization, 18 percent were considered uncertain and 14 percent were considered inappropriate.

The authors note that their data suggest higher revascularization rates in the U.S. compared to Canada may in part be related to higher rates of revascularization in patients with uncertain indications. "Future evaluation is needed to confirm whether discrepancies in appropriateness of coronary revascularization exist and whether they can be attributed to differences in implicit and explicit incentives associated with the different models of healthcare financing between the two countries," they add.

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However, "the rate of revascularization procedures classified as inappropriate should not be expected to be zero, as there are a myriad of clinical features and exceptions that are not accounted for by the limited scenarios for coronary revascularization," said Manesh Patel, MD, FACC, lead author of the 2012 appropriate use criteria for coronary revascularization focused update, in an editorial comment. "These rates do start to provide benchmarks so the providers and institutions can review practice patterns, and highlight indications and clinical areas that need better clarity in future AUC documents."

Patel adds that the study highlights the need for real-time clinical decision support tools to help guide use of revascularization, reduce the risk-treatment paradox, and improve patient outcomes. "The ACC, along with other stakeholders, should continue to encourage innovation and ensure systems are put into place to inform patients and physicians about coronary revascularization," he adds.

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