Appropriateness of Percutaneous Coronary Intervention

OBJECTIVES: Despite the widespread use of percutaneous coronary intervention (PCI), the appropriateness of these procedures in contemporary practice is unknown. The objective is to assess the appropriateness of PCI in the United States.

METHODS: Design, Setting, and Patients Multicenter, prospective study of patients within the National Cardiovascular Data Registry undergoing PCI between July 1, 2009, and September 30, 2010, at 1091 US hospitals. The appropriateness of PCI was adjudicated using the appropriate use criteria for coronary revascularization. Results were stratified by whether the procedure was performed for an acute (ST-segment elevation myocardial infarction, non–ST-segment elevation myocardial infarction, or unstable angina with high-risk features) or nonacute indication.

RESULTS: Of 500, 154 PCIs, 355 417 (71.1%) were for acute indications (ST-segment elevation myocardial infarction, 103, 245 [20.6%]; non–ST-segment elevation myocardial infarction, 105, 708 [21.1%]; high-risk unstable angina, 146, 464 [29.3%]), and 144 737 (28.9%) for nonacute indications. For acute indications, 350, 469 PCIs (98.6%) were classified as appropriate, 1,055 (0.3%) as uncertain, and 3,893 (1.1%) as inappropriate. For nonacute indications, 72, 911 PCIs (50.4%) were classified as appropriate, 54, 988 (38.0%) as uncertain, and 16, 838 (11.6%) as inappropriate. The majority of inappropriate PCIs for nonacute indications were performed in patients with no angina (53.8%), low-risk ischemia on noninvasive stress testing (71.6%), or suboptimal (≤1 medication) antianginal therapy (95.8%). Furthermore, although variation in the proportion of inappropriate PCI across hospitals was minimal for acute procedures, there was substantial hospital variation for nonacute procedures (median hospital rate for inappropriate PCI, 10.8%; interquartile range, 6.0%-16.7%).

CONCLUSIONS: In this large contemporary US cohort, nearly all acute PCIs were classified as appropriate. For nonacute indications, however, 12% were classified as inappropriate, with substantial variation across hospitals 

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Posted in Health Policy, Invasive Imaging and tagged , , .

6 Comments

  1. Almost all acute PCI and half of nonacute PCI in US meet appropriateness guidelines

    July 5, 2011 | Reed Miller

    Extenuating circumstances such as high-risk coronary anatomical findings not captured in the appropriate-use criteria are unlikely to account for more than a few of the procedures classified as inappropriate, Chan et al explain. Most of these PCIs are performed immediately following diagnostic angiography, without much discussion with the patient about the benefits and risks of PCI, so it is likely that clinician factors, rather than patient preference, are responsible for most of these procedures, the authors argue.

    The indications of uncertain appropriateness “represent gaps in knowledge and underscore the need for future outcomes-based studies to clarify the benefits of PCI,” the authors point out, adding that now that the appropriateness guidelines are well-known, “future studies of procedural appropriateness will need to account for potential ‘gaming’ of key variables used in appropriateness assessments, such as symptom severity.” Patient questionnaires to assess angina and routine data audits could also help to ensure integrity of appropriateness assessments, according to the authors.

  2. I feel that the guidelines are the real problem, that change everyday. Almost 50% acute PCI and 10% of nonacute PCI in the world will meet appropriateness guidelines in 2015.

  3. Chinadxy: 如果支架10元一个,还有人用吗?
    Translation: Will doctors prefer to use stents, if each stent was $1.50?

  4. Yingtiao:可惜国内无人做类似的研究。
    Translation: It’s a pity that there is no such research in China.

  5. The Maryland Medical Board has announced its final decision in its review of Dr. Mark Midei’s license in the “unnecessary stenting” imbroglio, concluding that he violated the Medical Practice Act in his treatment of five patients and calling his violations “repeated and serious.”

    1. “I pity any interventional cardiologist practicing in Maryland today; if Dr Midei can lose his license, any of them could.”

    2. he sometimes wrote “80%” as a form of shorthand for blockages that in fact were less than 50%, calling that “a justification for a blatant falsehood that resulted in patients receiving unneeded stents as well as the creation of false records.”

    3. If any interventional cardiologist wrote “80%” as a form of shorthand for blockages that in fact were less than 50% in USA,
    less than 10% of nonacute PCI meet appropriateness guidelines in this research.

  6. This kind of research is always very interesting. It’s great to read that only 0.1% of acute PCI procedures in the acute setting were inappropriate. It kind of makes sense as the guidelines for acute settings are going to be more flexible than the ones for non-acute settings.

    It was also really re-assuring to read that despite significant hospital variation, the relationship between a hospital’s annual nonacute PCI volume and its rate of inappropriate PCI was weak. OK, somewhat re-assuring…

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