September 18th, 2013
Both Overuse and Underuse Explain Disparities in Coronary Revascularization
A new study finds that groups who have often been found to receive less medical care — non-whites, women, and people without private insurance or who are from urban and rural areas — are less likely to undergo coronary revascularization. But the same study finds that this disparity may be in no small part due to the fact that these same groups are less likely to receive inappropriate procedures. The study, published online in the Journal of the American College of Cardiology, suggests, therefore, that the apparent underuse of healthcare in some groups may be partly counterbalanced by overuse in other groups.
Applying appropriate use criteria (AUC) to data from the National Cardiovascular Data Registry (NCDR), Paul Chan and colleagues found, consistent with previous studies, that 12.2% of the more than 211,000 non-acute PCIs performed between July 2009 and March 2011 were inappropriate. Digging deeper into the data they found:
- Men were more likely than women to receive an inappropriate PCI (adjusted odds ratio 1.08, CI 1.05-1.11, p < 0.001)
- Whites were more likely than non-whites to receive an inappropriate PCI (OR 1.09, CI 1.05-1.14, p < 0.001)
- Patients with Medicare were less likely than those with private insurance to receive an inappropriate PCI (OR 0.85, CI 0.83-0.88)
- Patients with other public insurance were less likely than those with private insurance to receive an inappropriate PCI (OR 0.78, CI 0.73-0.83)
- Patients with no insurance were less likely than those with private insurance to receive an inappropriate PCI (OR 0.56, CI 0.50-0.61)
- Patients treated at rural hospitals were less likely than those at urban hospitals to receive an inappropriate PCI (OR 0.92, CI 0.88-0.96)
- Patients treated at suburban hospitals were more likely than those at urban hospitals to receive an inappropriate PCI (OR 1.10, CI 1.07-1.13)
In an accompanying editorial, Karen Joynt points out the “flip side of poor quality” in which the “patterns of overuse of PCI were diametrically opposed to prior research on patterns of underuse.” She writes that it is quite likely that “there is concurrent underuse and overuse” of PCI, both of which need to be addressed: “Both sides of the quality paradigm – underuse and overuse – must be together at the forefront of our quality improvement efforts.”
In an interview with CardioExchange, Chan said that although “we have come a long way in ensuring that care is delivered equitably and thoughtfully in the US… there is no doubt that underuse in certain populations remains a persistent and huge problem. For policymakers… it highlights the importance of thinking about differences in treatment in a more complex way– as due to underuse and also potential overuse. Therefore, the goal may be to narrow the gap in vulnerable populations in instances where treatment has clearly established benefit rather than assuming that the measured difference is entirely due to a disparity in care.” Chan also said the paper was consistent with the hypothesis that patients for whom physicians are paid more are more likely to undergo inappropriate procedures.
In a statement issued by the American College of Cardiology, former ACC president Ralph Brindis said that “it is important to note that the Appropriate Use Criteria terminology has been updated since the creation of Dr. Chan’s manuscript from ‘Inappropriate’ to ‘Rarely Appropriate.’ The new terminology acknowledges that in certain rare cases when the patient’s individual circumstances are considered as part of a shared decision-making process, stents in this category would be considered ‘Appropriate.'” He acknowledged that “at present, we are better equipped to measure ‘Rarely Appropriate’ or overuse of care than determining the underuse of care. The American College of Cardiology is very concerned about racial and socioeconomic disparities in underuse of care.”