NCDR Study Sheds Light on Patient and Hospital Characteristics Linked to Inappropriate PCI

Non-acute percutaneous coronary interventions (PCIs) categorized as "inappropriate" using the ACC's Appropriate Use Criteria (AUC) are more commonly performed in "men, patients of white race and those with private insurance," according to a study published Sept. 18 in the Journal of the American College of Cardiology.

"For those physicians that are performing PCI, now specifically we are talking about elective PCI, I would advise doing whatever you can to really document the thought process - why that PCI was necessary, and why, even if it doesn't seem to meet the letter of the law for the AUC criteria, there were extenuating circumstances that made it the right thing to do clinically," said Deepak Bhatt, MD, FACC.

Overall results from the study showed that 25,749 (12.2 percent) of the 221,254 non-acute PCIs from 1,071 hospitals enrolled in the ACC's CathPCI Registry between July 2009 and March procedures were classified as inappropriate. After multivariable adjustment, men (adjusted OR, 1.08 [95 percent CI: 1.05-1.11]; P<0.001) and whites (adjusted OR, 1.09 [1.05-1.14]; P<0.001) were more likely to undergo an inappropriate PCI as compared to women and non-whites. In addition, privately insured patients were more likely to receive an inappropriate PCI procedure, compared to patients with Medicare, public insurance or no insurance.

The results also found that "patients without heart failure, left ventricular dysfunction, or known coronary artery disease, as well as patients undergoing pre-operative evaluation for non-cardiac surgery, were more likely to undergo PCI categorized as inappropriate." Further, the results also highlighted differences between hospital type, with patients admitted to suburban hospitals more likely to undergo inappropriate PCI, than those admitted to rural hospitals. "The reason for this treatment pattern is unknown but may be related to decreased availability of interventional cardiologists at rural hospitals or different cultures of practice and patient preferences within different hospital settings," the authors said.

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Moving forward, the authors note that the study findings can provide important insights into specific patient and hospital characteristics where the risks of PCI may exceed the benefits. "Although underuse of treatment leads to disparities in care, our findings suggest potential overuse of PCI in these patient groups may also account for some of the previously observed differences in care," they said. However, they do caution that "avoiding PCIs that may not confer a clear clinical benefit in pre-operative patients can be complex and challenging as it involves not only the cardiologist but also the referring physicians and surgeon."

In a related editorial comment, Karen E. Joynt, MD, MPH, division of cardiovascular medicine, Brigham and Women's Hospital, Boston, MA, urges a "multi-pronged approach" focused on both overuse and underuse in order to optimize quality in cardiovascular care. The study findings "are important because they make clear the types of interventions that are most (and least) likely to be effective in improving the overall quality of care delivered for cardiovascular disease," she said. The study authors offer a similar conclusion, saying that "efforts to reduce inappropriate PCIs in pre-operative patients will … require concerted efforts to provide educational outreach to primary care physicians, cardiologists, and non-cardiac surgeons alike."

Method of Revascularization of Multivessel Coronary Artery Disease (Click to Enlarge)

"These types of studies further our understanding and call attention to the need for standardized follow up and methods of AUC evaluation," said Manesh R. Patel, MD, FACC, lead author of the ACC's AUC for PCI, and assistant professor of medicine and director of Interventional Cardiology and Cath Labs at Duke University Health System in Durham, NC. He suggests that revascularization procedures deemed ‘appropriate' should also be reviewed as they may represent underuse and also highlight disparities in care with the same populations gaining more access to care.

Keywords: Coronary Artery Disease, Follow-Up Studies, Physicians, Primary Care, Heart Failure, Medicare, Cardiac Surgical Procedures, Ventricular Dysfunction, Left, Patient Preference, United States, Percutaneous Coronary Intervention

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