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PCI appropriateness in US varies from acute, non-acute indications
Chan P. JAMA. 2011;306:53-61.
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New data from a large US cohort have suggested that nearly all of the percutaneous coronary intervention procedures performed for an acute indication were appropriate, although 12% were classified as inappropriate when the indication was non-acute.
The multicenter, prospective study involved 500,154 PCI procedures performed in 1,091 US hospitals from July 2009 to September 2010. Of these, 71.1% were for acute indications (STEMI, non-STEMI and high-risk unstable angina) and 28.9% were for non-acute indications. Appropriateness of PCI in 198 distinct and mutually exclusive clinical indications was determined by a 17-member expert panel using a modified Delphi approach.
Among the acute indications for PCI, 98.6% were performed appropriately, whereas 1.1% were classified as inappropriate and 0.3% as uncertain. However, in the non-acute setting, only 50.4% of procedures were found to be appropriate, with 38% classified as uncertain and 11.6% as inappropriate.
Furthermore, in the non-acute indication, researchers found that most inappropriate PCIs were performed in patients with suboptimal antianginal therapy (≤1 medication; 95.8%), low-risk ischemia on noninvasive stress testing (71.6%) or with no angina (53.8%), and they also reported a substantial variation across hospitals.
The researchers said these findings point toward new challenges and directions required for assessing the overall appropriateness of PCI. “Better understanding of the clinical settings in which inappropriate PCIs occur and reduction in their variation across hospitals should be targets for quality improvement,” they concluded.
What is important about this study is its use of the most reliable data - clinical data, not administrative data - to demonstrate the vast majority of interventional cardiologists are making well-founded and appropriate decisions about when to perform PCI. The findings of this study should be reassuring to our colleagues in other specialties and our patients. It shows interventional cardiologists are doing an excellent job with acute indications and a good job with elective patients. Going forward, the study also helps us identify opportunities for improvement in clinical practice, such as where the appropriate use criteria are 'uncertain' and doctors need to evaluate more clinical variables and quality-of-life considerations. The professional medical societies - SCAI and ACC, among others - have responded to give us tools for quality improvement that will help us.
– Gregory J. Dehmer, MD
Spokesperson, Society for Cardiac Angiography and Interventions
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