July 5th, 2011

Only Half of Nonacute PCIs Deemed Appropriate

Only half of all PCIs performed for nonacute cases have a definite indication, according to a report from the National Cardiovascular Data Registry published in JAMA. Paul Chan and colleagues analyzed data from more than half a million PCI procedures performed between July 1, 2009 and September 30, 2010.

Out of 500,154 PCIs, they found that 355,417 (71.1%) were for acute indications:

  • STEMI: 103,245 (20.6%)
  • Non-STEMI: 105,708 (21.1%)
  • High-risk unstable angina: 146,464 (29.3%)

The remainder — 144,737 (28.9%) — were for nonacute indications.

The vast majority (98.6%) of PCIs for acute indications were classified as appropriate. By contrast, only half (50.4%) of those for nonacute indications were classified as appropriate; 38% were classified as uncertain, while 11.6% were considered inappropriate.

Among the nonacute cases deemed inappropriate:

  • 53.8% were in patients with no angina
  • 71.6% were in patients who had low-risk ischemia on noninvasive stress testing
  • 95.8% were in patients taking fewer than two angina medications.

For the acute cases, there was little variation in the rate of inappropriate procedures across hospitals. For the nonacute cases, however, substantial inter-hospital variation was observed: the rate of inappropriate procedures for nonacute cases ranged from 6% or less in the lowest quartile compared with 16% or greater in the highest quartile. The authors write that the high rate in this group “suggests overuse of PCI in these hospitals and an important opportunity for improvement in patient selection.”

The authors acknowledge that some of the procedures classified as inappropriate “may be explained by extenuating circumstances,” but say such circumstances were unlikely to explain the majority of procedures. In addition, although patient preference may explain some inappropriate procedures, the authors point out that many patients overestimate the benefits of PCI and that most PCIs are performed immediately following diagnostic angiography, allowing little opportunity for a serious discussion with the patient.

The authors conclude that “better understanding of the clinical settings in which inappropriate PCIs occur and reduction in their variation across hospitals should be targets for quality improvement.”

One Response to “Only Half of Nonacute PCIs Deemed Appropriate”

  1. It is important to keep in mind that, while 50% of non-acute PCIs were categorized as appropriate (suggesting definite or probable clinical benefit), another 38% of non-acute PCIs were categorized as uncertain in appropriateness (suggesting possible clinical benefit).

    Nonetheless, the 12% inappropriate non-acute PCI rate, coupled with substantial variation in hospital rates of inappropriate non-acute PCIs, suggests important opportunities to improve the value of care delivered to our patients. To accomplish this, however, we will need to engage both interventional and non-interventional physicians to candidly and thoughtfully examine patterns of referal and treatment in their practices.

    Competing interests pertaining specifically to this post, comment, or both: