PCI Appropriateness for Nonacute Indications Still Varies, Needs Improvement

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In a large cohort of patients in Washington State, only 1% of percutaneous coronary interventions (PCI) performed for acute indications were deemed inappropriate, according to a study published online May 8, 2012, ahead of print in Circulation: Cardiovascular Quality and Outcomes. However, in PCIs performed for nonacute indications, inappropriate procedures were reported 17% of the time.

For the study, Steven M. Bradley, MD, MPH, of the University of Colorado Denver (Denver, CO), and colleagues assessed 13,291 PCI procedures performed at 31 Washington hospitals in 2010. Three quarters (n = 9,924) were then classified as appropriate, uncertain, or inappropriate based on the Appropriate Use Criteria for Coronary Revascularization developed by the American College of Cardiology Foundation. Missing data or unclassifiable clinical scenarios were to blame for the remaining 3,367 nonclassified procedures.

Of the classified PCI procedures, 71% (n = 8,010) were performed for treatment of acute indications, for which appropriateness levels were high. In PCI procedures performed for nonacute indications (n = 1,914), less than half were deemed appropriate (table 1).

Table 1. PCI Appropriateness by Indication

 

Appropriate

Uncertain

Inappropriate

All Classified PCI

88%

8%

4%

Acute Indications

98%

< 1%

1%

Nonacute Indications

44%

39%

17%


The most common acute indications were non-STEMI or unstable angina with high-risk features (n = 5,900; 62%) and acute STEMI (n = 2,144; 23%). These indications were classified as appropriate in 94% of cases, with 6% not classified.

The majority of PCI procedures (68%) were performed without documented noninvasive stress test results. Sensitivity analysis, however, estimated results for missing stress tests in nonacute indications, showing a range in appropriateness from 8% in the best-case scenario where results were assumed as high risk to 38% in the worst-case scenario where results were assumed as low risk.

When looking at facility-specific outcomes, inappropriateness variability was minimal but greatest for nonacute indications, including those for which missing data resulted in an inability to classify procedure appropriateness.

New Era for PCI

According to Dr. Bradley and colleagues, the development and active application of these appropriateness criteria could represent a new era for the improvement of quality care surrounding PCI.

“The creation of a quality measure to ascertain whether a stent was appropriate before placement allows for the entirely new and standardized measurement of anticipated procedural benefit relative to the risk of procedural harm,” they write.

In a telephone interview with TCTMD, Dr. Bradley added that clinicians should begin to use these criteria in their day-to-day clinical practice, “given that they reflect our current understanding of clinical trial evidence and practice guidelines in terms of anticipated benefits of PCI for given clinical scenarios.”

Edward L. Hannan, PhD, of the University of Albany, State University of New York (Albany, NY), who was part of a study that examined PCI appropriateness criteria in New York State, agreed with Dr. Bradley. In a telephone interview with TCTMD, he added that the incorporation of these criteria should be relatively easy.

“Hospitals could have a [wallet-sized] card or a succinct description of what constitutes an appropriate PCI,” Dr. Hannan suggested.

Opportunities for Improvement

Although these results are in line with the results of both the national and New York State studies, Dr. Bradley said they demonstrate considerable variation in PCI appropriateness for nonacute indications. This suggests that in broad practice there are opportunities to improve patient selection and ensure that patients are actually benefitting from PCI.

“There are also challenges with applying the criteria as evidenced by the missing [stress test data],” Dr. Bradley added.

Dr. Hannan pointed out the inevitable exceptions in real-world application of the criteria.

“You can see something rated uncertain or inappropriate and there were extenuating circumstances that have to do with rare problems that patients have,” Dr. Hannan said. “There should be a way in which hospitals could refute the criteria for those isolated incidents and have the case overturned for that particular patient.”

However, these cases would be the exceptions and not the norm, Dr. Hannan added. Instead, the cardiology community should begin to clarify what exactly constitutes extenuating circumstances and make this information more transparent and public.

In addition, Dr. Hannan said that because PCI is a more expensive treatment than medical therapy, more work should be done to eliminate uncertain classifications and to judge all procedures as either appropriate or inappropriate based on emerging evidence.

Study Details

Patients were predominantly white, male, and older than 60 years. Coronary risk factors, prior history of coronary disease or revascularization, and comorbid conditions were common.


Source:

Bradley SM, Maynard C, Bryson CL. Appropriateness of percutaneous coronary interventions in Washington State. Circ Cardiovasc Qual Outcomes. 2012;Epub ahead of print.

Disclosures:

  • Drs. Bradley and Hannan report no relevant conflicts of interest.

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