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Most Percutaneous Coronary Interventions (Such As Balloon Angioplasty) Performed in U.S. For Acute Indications Appear to be Warranted
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July 5, 2011 -- Chicago --
In an examination of the appropriateness of the widespread use of percutaneous
coronary interventions (PCIs), researchers found that of more than 500,000 PCIs
included in the study, nearly all for acute indications were classified as appropriate,
whereas only about half of PCIs performed for nonacute indications could be classified
as appropriate, according to a study in the July 6 issue of JAMA.
According to background information in the
article:
"Approximately 600,000 percutaneous
coronary interventions [procedures such as balloon angioplasty
or stent placement
used to
open narrowed coronary arteries] are performed in the United
States each year, at a cost that exceeds $12 billion. Patients
who undergo
PCI are exposed to risks of periprocedural complications and
longer-term bleeding and stent thrombosis. Moreover, recent trials
in stable patients
without acute coronary syndromes have shown that PCI, compared
with medical therapy, may provide only a modest population-average
improvement
in symptom relief. Given the cost and
invasiveness of PCI, determining the extent to which PCI procedures
are performed for appropriate
and inappropriate indications could identify procedural overuse
and areas
for quality improvement and cost savings."
Recently, appropriate use
criteria for coronary revascularization were jointly developed
by 6 professional organizations to support the rational and judicious
use
of PCI.
Paul S. Chan,
MD, MSc |
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Paul S. Chan, M.D., M.Sc., of
Saint Luke's Mid America Heart and Vascular Institute, Kansas
City, Mo., and colleagues conducted a study to quantify the proportion
of PCIs classified as appropriate, of uncertain appropriateness,
and as inappropriate for acute as well as nonacute indications.
The
study included data from patients within the National Cardiovascular
Data Registry undergoing PCI between July 2009 and September
2010 at 1,091 U.S. hospitals. The appropriateness of PCI was
determined using the appropriate use criteria for coronary
revascularization. |
Results were stratified
by whether the procedure was performed for an acute indication (ST-segment
elevation myocardial infarction - a certain pattern on an electrocardiogram
following a heart attack; non-ST-segment elevation myocardial infarction,
or unstable angina with high-risk features) or nonacute indication
Of 500,154 procedures classified, 103,245 (20.6 percent) were for ST-segment elevation myocardial infarction, 105,708 (21.1 percent) for non-ST-segment elevation myocardial infarction, 146,464 (29.3 percent) for high-risk unstable angina, and 144,737 (28.9 percent) for nonacute elective indications. Based on the appropriate use criteria definition for acute procedures, 355,417 PCIs (71.1 percent) were for acute indications and 144,737 (28.9 percent) were for nonacute indications. Heart attack comprised 58.8 percent of all acute procedures, while high-risk unstable angina comprised 41.2 percent.
The researchers found that the vast majority (98.6 percent) of acute PCIs were classified as appropriate, with 0.3 percent classified as uncertain and 1.1 percent as inappropriate. Overall, 50.4 percent of nonacute PCIs were classified as appropriate, while 38.0 percent were for uncertain indications and 11.6 percent were for inappropriate indications. In general, compared with procedures classified as appropriate and uncertain, inappropriate PCIs were more likely to occur in patients with no angina, low-risk non-invasive stress testing results or suboptimal antianginal therapy.
There was substantial hospital-level variation in the proportion of inappropriate procedures for nonacute indications. Hospitals in the lowest quartile had rates of inappropriate PCI of 6 percent or lower, while the rate of inappropriate PCI was greater than 16 percent among hospitals in the highest quartile. Analysis of the data suggested an 80 percent greater likelihood of patients with identical clinical characteristics receiving an inappropriate PCI at one randomly selected hospital as compared with another.
"Collectively, these findings suggest an important opportunity to examine and improve the selection of patients undergoing PCI in the non-acute setting," the
authors write.
"Better understanding of the clinical settings
in which inappropriate PCIs occur and reduction in their variation
across hospitals should be targets for
quality improvement."
Source: Journal of the American Medical Association
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