JACC in a Flash | Is Overuse as Bad as Underuse? Factors Leading to Inappropriate PCI

Percutaneous coronary intervention (PCI) is a common procedure—its use accounts for approximately 600,000 procedures and $12 billion in health care spending annually in the United States; however, in certain subpopulations, its use is much lower. In an attempt to explain these disparities in care, Paul S. Chan, MD, MSc, and colleagues examined the potential underuse of PCI in “traditionally vulnerable” populations (blacks, women, and those with public or no health insurance), as well as investigating overuse in whites, men, and individuals with private insurance.

Of the 211,254 non-acute PCIs included in the NCDR® CathPCI Registry® that Dr. Chan and researchers analyzed, 105,121 (49.8%) were classified as “appropriate,” 80,384 (38.1%) as “uncertain,” and 25,749 (12.2%) as “inappropriate.” Compared with patients undergoing appropriate PCIs, patients with inappropriate PCIs were more frequently men, of white race, and privately insured (TABLE).

Table: Predictors of Inappropriate PCI
  Adjusted OR (95% CI; p Value)
Men 1.08 (1.05-1.11; p < 0.001)
White 1.09 (1.05-1.14; p < 0.001)
Health Insurance (reference = Private insurance)
Other public insurance
0.85 (0.83-0.88; p < 0.001)
0.78 (0.73-0.83; p < 0.001)
0.56 (0.50-0.61; p < 0.001)
Family history of CAD 0.89 (0.86-0.92; p < 0.001)
Prior myocardial infarction 0.84 (0.81-0.86; p < 0.001)
Prior PCI or CABG 0.73 (0.70-0.75; p < 0.001)
Hospital location (reference = Urban)
0.92 (0.88-0.96; p < 0.001)
1.10 (1.07-1.13; p < 0.001)
Patients were also more likely to have a preoperative evaluation for noncardiac surgery than patients with PCIs categorized as appropriate (8.9% vs. 2.6%; p < 0.001). In terms of hospital characteristics and their impact on appropriateness rates of PCI, patients admitted at rural hospitals were the least likely to undergo a PCI without clear clinical benefit, whereas patients admitted at suburban hospitals were the most likely.

“Collectively, these findings provide important insights into which patient and hospital characteristics are associated with a PCI for stable coronary artery disease in whom the risks of the procedure may exceed its benefits,” Dr. Chan and co-authors concluded. “While the clinical magnitude of the [demographic] differences was modest, it represents over 2,000 additional procedures per year in which male and white patients may be exposed to procedural and long-term bleeding risks without clear clinical benefit over that of medical therapy.”

One potential explanation for this treatment pattern: blacks, women, the uninsured, or those residing in rural locations may be treated later in the course of their coronary artery disease than those with greater access to care. These patient groups may be more symptomatic prior to coronary angiography and PCI, thus leading to lower rates of inappropriate procedures. “This pattern of care among traditionally vulnerable populations would not be intrinsically problematic, as it may simply reflect good clinical decision making, as long as it is also not accompanied by concurrent underuse of PCI for appropriate indications,” the authors added. “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.”

In an accompanying editorial, Karen E. Joynt, MD, MPH, questioned whether overuse is actually as problematic as underuse, particularly in terms of economic and clinical consequences. While overuse of PCI leads to needless spending without clinical benefit, the clinical consequences are more complex. “Inappropriate PCI surely leads to unnecessary exposure to risk; however, given that in general, the patients on whom procedures are overused are a healthier group undergoing elective procedures, their outcomes are still good,” Dr. Joynt wrote. “The clinical consequences of overuse thus remain largely invisible, at least on a population level.”

Ultimately, Dr. Joynt agreed with the implications of the study by Chan et al.: both sides of the quality paradigm—underuse and overuse—must be together at the forefront of quality improvement efforts.

Chan PS, Rao SV, Bhatt DL, et al. J Am Coll Cardiol. 2013 September 6. [Epub ahead of print]
Joynt KE. J Am Coll Cardiol. 2013 September 6. [Epub ahead of print]

Keywords: Quality Improvement, Registries, Vulnerable Populations, Hospitals, Rural, Percutaneous Coronary Intervention

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