NorthPoint Domain

Cardiology: Analysis Finds Most PCIs Appropriate

by Robert Fay

An analysis published recently in the Journal of the American Medical Association found that nearly all percutaneous coronary interventions (PCIs) performed for acute indications in the United States met 2009 appropriate use criteria, but the results were not as good for elective PCI.

Approximately 600,000 PCIs are performed annually in the United States at a cost of more than $12 billion. Despite its widespread use, the appropriateness of PCI is unknown. Given the cost and invasiveness of the procedure, determining which PCIs are inappropriate could help identify overuse of the procedure, areas of quality improvement, and cost savings. Thus, the authors compared data from part of the National Cardiovascular Data Registry, the CathPCI registry, with appropriate use criteria published in 2009. The main outcome measures were the proportion of acute and non-acute PCIs classified as appropriate, uncertain, or inappropriate as well as the extent of hospital-level variation in inappropriate procedures.

The study included information from 500,154 PCIs performed between July 1, 2009 and September 30, 2010 at 1,091 U.S. hospitals. A total of 355,417 (71.1 percent) of the procedures were for acute indications: 103,245 (20.6 percent) for ST-segment elevation myocardial infarction (STEMI); 105,708 (21.1 percent) for non-STEMI, and 146,464 (29.3 percent) for high-risk unstable angina. The authors identified 144,737 (28.9 percent) non-acute PCIs. Of the acute indications, 350,469 (98.6) percent were appropriate, 1,055 (0.3 percent) were of uncertain benefit, and 3,893 (1.1 percent) were inappropriate. For non-acute procedures, 72,911 (50.4 percent) were appropriate, 54,988 (38 percent) were of uncertain benefit, and 16,838 (11.6 percent) were inappropriate. Most inappropriate PCIs for non-acute indications were performed in patients with no angina, low-risk ischemia on non-invasive stress testing, or suboptimal antianginal therapy, defined as one or fewer medications. The proportion of appropriate versus inappropriate acute PCI varied little across hospitals. However, for non-acute PCI, the authors noted substantial variation.

The authors conclude that based on the results of the current study, “Better understanding of the clinical settings in which inappropriate PCIs occur and reduction in their variation across hospitals should be targets for quality improvement.”

Source: Chan PS, Patel MR, Klein LW, et al. 2011. Appropriateness of percutaneous coronary intervention. Journal of the American Medical Association 306(1): 53-61.