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Varied rates of obstructive CAD suggest quality-improvement efforts
Douglas P. J Am Coll Cardiol. 2011;58:801-809
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Varied rates of finding obstructive coronary artery disease at elective coronary angiography among reporting centers suggests an opportunity for quality-improvement efforts, according to a study.
Data on 565,504 patients recorded from 2005 to 2008 in the National Cardiovascular Data Registry (NCDR) CathPCI Registry was analyzed “to determine variation in hospitals’ rate of finding obstructive CAD at elective coronary angiography performed in patients without known CAD” at 691 US hospitals. Only patients without a previous diagnosis of CAD who were undergoing elective coronary angiography were identified in the overall CathPCI Registry cohort, according to researchers.
Obstructive coronary disease found at elective coronary angiography among hospitals varied from 23% to 100%. These rates held year-to-year consistency, even when alternative definitions of coronary stenosis were applied. The CAD rate was lower at reporting centers with small volume catheterization laboratories. Patients studied at low-rate centers were less likely to have stable angina symptoms, positive stress tests before coronary angiography, and been prescribed cardiac medications before angiography. According to the study, patients in low-rate centers were also “younger, had a lower likelihood of disease, and who were less likely to have had a noninvasive evaluation demonstrating ischemia before coronary angiography.” In 2005, the overall rate of finding obstructive CAD was constant at 44.4%. In 2008, it was constant at 45.6%.
“The institutional CAD rate was associated with baseline cardiac risk, chest pain characteristics, noninvasive test performance and results, and intensity of pre-procedural medical therapy, but there were few relationships with nonclinical or institutional factors,” researchers wrote. “This suggests that local clinical practice patterns may be the most influential factor in guiding use of diagnostic coronary angiography and could be a target for quality-improvement efforts, including appropriate use criteria development. A balanced consideration of all the relevant steps inherent in a decision to proceed to elective invasive coronary angiography, as well as the finding of CAD at catheterization, is needed to optimize coronary angiography utilization.”
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