Poll Results: Managing PCI Overuse in Stable Ischemic Heart Disease
- A recent data analysis suggests incorporation of the recent ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) results in appropriate-use criteria could decrease elective percutaneous coronary interventions (PCI) sevenfold.
- US False Claims Act investigations identify blatant over-use of PCI in certain hospitals, but there appears to be a secondary phenomenon of PCI reductions in non-investigated hospitals.
A recent publication in JAMA Internal Medicine by Malik et al.1 calculates the impact of the ISCHEMIA results if incorporated into updated appropriate-use criteria for the frequency of rarely appropriate PCI in stable, asymptomatic patients. Based on these calculations, the expected reduction in PCI procedures for stable, asymptomatic patients would be sevenfold.
In an accompanying article, Howard et al.2 suggest that investigations of unnecessary PCI may have contributed to parallel reductions in non-investigated hospitals, although declines would have likely fallen secondary to the results of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial. It goes without stating that inappropriate PCI and/or incorrect documentation cannot be tolerated, but the effect that governmental contractual investigations have on in non-investigated hospitals must be examined.
In a recent poll, we asked the question "To what extent do you believe investigations should potentially influence sound, individualized clinical patient care decisions?" The majority of the modest number of responses indicated that guidelines and clinical judgement are the appropriate way to make sound clinical decisions without external legal threats. This seems an expected physician response but does come with an explicit requirement that physicians practice professionally and follow reasonable standards for patient care. Likewise, self-management of practices must remain a standard to assure appropriate medical care decisions.
- Malik AO, Spertus JA, Patel MR, et al. Potential Association of the ISCHEMIA Trial With the Appropriate Use Criteria Ratings for Percutaneous Coronary Intervention in Stable Ischemic Heart Disease. JAMA Intern Med 2020;Sep 21:[Epub ahead of print].
- Howard DH, Desai NR. US False Claims Act Investigations of Unnecessary Percutaneous Coronary Interventions. JAMA Intern Med 2020;Sep 21:[Epub ahead of print].
Clinical Topics: Invasive Cardiovascular Angiography and Intervention
Keywords: Coronary Angiography, Percutaneous Coronary Intervention, Self Care, Drug Evaluation, Hospitals, Patient Care, Internal Medicine
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