February 22nd, 2012

Part 5: Clashing Views of Appropriate Use Criteria for PCI

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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 1Part 2Part 3, and Part 4 of this debate. This is the final installment of this series.

Lange & Hillis: What is the acceptable threshold for inappropriate PCI for non-acute patients?

Chan & Spertus: We do not currently have an absolute threshold that is ‘acceptable’. However, the variability across centers for non-acute PCIs, ranging from 0 to >50%, is clearly unacceptable and suggests that some patients are being treated because of who their doctor is, rather than the severity of their disease and their potential to benefit from revascularization.

Marso & Grantham: In an ideal world, the inappropriate rate should approach 0%. However, given the complexities of measuring appropriateness, the writing committee rightly established the inappropriate rate at “national norms”, which unfortunately remains elusive. Revealing the true norm will be a challenge and will require a rework of the AUC methodology.



One Response to “Part 5: Clashing Views of Appropriate Use Criteria for PCI”

  1. This is an important point. The goal of Appropriate Use Criteria and many of the Guidelines are to provide the best recommendation on what is reasonable and appropriate care. This information is used in discussion with patients and to help them make decisions and provide their preferences, and more globally evaluate practice patterns to hopefully identify areas of improvement. The criteria readily acknowledge that they can not substitute for sound clinical judgement or provide scenarios for all the clinical situations in medicine and cardiology. Therefore, it would never be expected that the rate of non-elective PCI’s classified as “inappropriate” would be zero since exceptional or unmeasured clinical circumstances should always prevail. However, the review of AUC does provide areas for consideration (both for the AUC writing group to review indications) but also for clinicians (such as the wide variation in PCI’s performed in asymptomatic patients alluded to above).