November 12th, 2010
This week, JAMA published a commentary that Harlan Krumholz and I wrote about the growing use of ad hoc PCI and its implications for decision making about coronary revascularization. To cut to the chase, we believe that ad hoc PCI — the performance of a diagnostic cath and PCI in the same setting — makes it challenging to incorporate findings from landmark studies like the COURAGE and SYNTAX trials into routine clinical practice. As a solution, we suggest that in stable patients, interventionalists consider “pausing” for a few days between the diagnostic cath and the PCI. Bill Boden — the lead investigator of the COURAGE trial — is currently exploring the feasibility of implementing such a waiting period in a collaborative effort with payers in upstate New York. Existing payment systems often discourage two separate settings for diagnostic cath and PCI because doing them at the same time is deemed more efficient. However, we are concerned that we may be performing PCI on patients who would have done just as well with optimal medical therapy or whose coronary anatomy would have been better suited to coronary bypass surgery.
But I think the biggest hurdle that Bill and others may face in such endeavors is the public’s distorted view of PCI. A recent study shows that patients continue to have outsized expectations about the benefits of PCI that are simply unjustified by the available evidence. As an interventionalist, I’ve found that patients (and referring providers) frequently arrive at the cath lab with the belief that if a blockage is found, it should be “fixed” right away. This places undue pressure on everyone to make immediate decisions that may not be in the best interest of the patient.
So, do others feel this type of pressure as well? Is a “pause” something that physicians, insurers, and patients would agree to implement in your practice?