February 21st, 2012
Part 4: Clashing Views of Appropriate Use Criteria for PCI
In a recent Viewpoint in JACC: Cardiovascular Interventions, Marso and colleagues expressed grave reservations about the application of appropriate use criteria for PCI in a controversial study published last year in JAMA by Chan and colleagues, which found that only half of PCIs performed for nonacute indications were classified as appropriate. Interventional cardiology editors Rick Lange and David Hillis asked CardioExchange members for their opinions on this topic. In this series of posts, Lange and Hillis question the main protagonists in the debate, Steven Marso and Aaron Grantham, on the one side, and Paul Chan and John Spertus on the other side. All the authors are affiliated with the Saint Luke’s Mid America Heart Institute in Kansas City, Missouri. Click for Part 1, Part 2, and Part 3 of this debate.
Lange & Hillis: According to the study by Chan et al, only 50% of PCIs performed for non-acute indications were deemed to be appropriate; 38% were said to be “uncertain” and 12% inappropriate. In your opinion, is this a reflection of (a) obsolete AUC criteria, (b) unreliable data for determining appropriateness, or (c) PCI procedures being performed unnecessarily? Would the results be different if the 2012 updated AUC were utilized?
Chan & Spertus: We believe that these are the best data available and that the publication is leading to substantial reflection about the indications for PCI. This is a very healthy process, as emphasized by the recent perspective of Marso and colleagues. It is prompting numerous innovative strategies among hospitals around the country to improve care, including a) deferring PCI in some cases that are inappropriate; b) supporting ‘cath conferences’ that discuss the indications for treatment, rather than just rates of procedural success or failure; c) encouraging the prospective assessment of appropriateness and implementing ‘mandatory second opinions’ in the cath lab prior to conducting procedures deemed inappropriate; and d) improving documentation and the quality of data abstraction. We believe that the 2012 update will further improve the accuracy of mapping patients and will reflect the latest available clinical data. Improvements in rates of PCI appropriateness are likely to reflect all of theses changes, including improved documentation, data abstraction and patient selection.
Marso & Grantham: In the Chan paper, the overall inappropriate rate for all PCIs was 4.2%. You are referencing the “I” rate for the non-acute PCI indications. The inappropriate rate of 12% in the non-acute indications may a function of all of the things you mention. However, it is likely that obsolete criteria do not play a deterministic role in the inappropriate rate.
We believe the data for stress testing and likely CCS is unreliable in the NCDR. The inappropriate rate is also a function of clinicians seeing relative value for CCS 2 and/or 12B when the AUC technical panel does not. Recall there was broad disagreement between the AUC technical panel and clinicians when assessing the appropriateness of this category. Certainly the “I” rate is also a function of inappropriate PCI being performed. We just cannot be certain whether this is a significant or minor fraction of the reported I rate of 12%.