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Only slightly more than one-third of percutaneous coronary interventions (PCI) among elective patients are considered appropriate, half are of uncertain value, and the remainder are deemed inappropriate. On the other hand, the vast majority of coronary artery bypass graft (CABG) surgeries in such patients fall within guidelines for appropriateness, according to registry data published in the May 22, 2012, issue of the Journal of the American College of Cardiology.

Investigators led by Edward L. Hannan, PhD, of the University at Albany, State University of New York (Albany, NY), analyzed New York State CABG and PCI registry data for all CAD patients without acute coronary syndromes (ACS) or prior CABG who underwent revascularization between July 2009 and December 2010. Cases were categorized as appropriate, inappropriate, or uncertain according to the 2009 American College of Cardiology Foundation (ACCF) appropriate use criteria. Due to insufficient hospital information, only 8,168 of 10,460 CABG patients and 24,545 of 33,970 PCI patients could be rated.

Big Difference Between PCI, CABG Appropriateness

Nine out of 10 CABG procedures were considered appropriate, while most of the rest were ranked as uncertain. By contrast, slightly more than one-third of PCI cases were rated appropriate and half were deemed to be of uncertain appropriateness (table 1).

Table 1. Appropriateness of Revascularization by Therapy

The researchers characterized various clinical scenarios associated with the PCI ratings and their frequency. While all patients had 1- or 2-vessel CAD with no proximal LAD involvement, a rating of inappropriate or uncertain PCI was typically associated with no or moderate symptoms or low stress test risk (or both). Moreover, 91% of inappropriate procedures involved no or minimal anti-ischemic medical therapy (table 2).

Table 2. Most Common Clinical Scenarios for PCI Patients by Rating

CCS, Canadian Cardiovascular Society
Class I: Angina only during strenuous or prolonged physical activity
Class II: Slight limitation, with angina only during vigorous physical activity

For PCI hospitals with volumes of more than 400 cases per year (n = 46), the percentage of inappropriate procedures varied from 1% to 40%, with most falling in the 6%-10% range. However, there was little correlation between hospital volume and procedure inappropriateness.

CABG Appropriateness Not an Issue

The authors suggest that CABG was rarely inappropriate because surgical patients tended to have severe CAD (3-vessel or left main disease). Also, CABG use may be limited by its higherrisk and more invasive nature.

On the other hand, many patients receiving PCI did not meet any of the 3 key criteria for appropriate revascularization: being on maximal anti-ischemic medical therapy, having high-risk stress test findings, or having CCS class II or IV symptoms.

Moreover, the likelihood of undergoing PCI depended to a large extent on the hospital in which patients were treated. Thus, Dr. Hannan and colleagues observe, even though some interventional cardiologists disagree with aspects of the appropriate use criteria, as a group they are inconsistent in how they select candidates for PCI.

Another important finding is that in about 28% of PCI patients, an appropriateness rating could not be determined. The main reasons, the investigators say, were either that, when required, no documentation of noninvasive test results was available or the results were not specific enough to determine whether they were highly positive.

Getting Ahead of the Curve

In an accompanying editorial, John Spertus, MD, MPH, and Paul Chan, MD, MSc, both of Saint Luke’s Mid America Heart Institute (Kansas City, MO), note that although virtually all patients undergoing PCI in the setting of ACS are treated appropriately, the current study reinforces an earlier National Cardiovascular Disease Registry analysis (Chan PS, et al. JAMA, 2011;306:53-61) in suggesting that “there are opportunities to improve patient selection for PCI.”

“The truth is that we may be doing exactly the right number of revascularization procedures in this country—we just have to be sure that we are doing them in the right patients. The [appropriate use criteria] are an important first step in addressing this issue,” Drs. Spertus and Chan conclude.

In a telephone interview with TCTMD, William E. Boden, MD, of the Albany Stratton VA Medical Center (Albany, NY), said what is especially disturbing is that 46% of patients in the ‘uncertain’ category received PCI absent of any objective evidence of ischemia or any trial of medical therapy. “That blows me away,” he said.

Moreover, Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), told TCTMD in a telephone interview that most of the uncertain PCI cases were very likely inappropriate.

Dr. Boden agreed, and underlined the potential impact of this pattern on interventional practice. In the near future, inappropriate procedures are likely to be scrutinized by the New York State health commissioner to determine whether they deserve reimbursement, he said.

In fact, a backlash from one important payer has already begun, Dr. Brener reported. In New York State, Medicaid no longer reimburses for inappropriate procedures. “I’m sure other payers will soon follow suit,” he added.

Going After the ‘Low-Hanging Fruit’

“Now that we have evidence from national and New York State data, we should at least address the low-hanging fruit. There are some fairly egregious excesses that should be eliminated,” Dr. Boden said, adding that denying payment for such cases is appropriate.

“But the bigger issue is getting more specificity around the ‘uncertain’ group,” he commented. “Going forward, we need more accountability for documenting performance of a stress test. Also, currently in the New York State database there is not a lot of detail about what medical therapy consists of or what constitutes an adequate trial of medical therapy. That needs to be clarified.”

One way to improve the appropriateness of PCI is prospective peer review, Dr. Boden said. In this process, once criteria for performing the procedure have been established, periodically a certain number cath films are randomly selected for review. When operators know they are being watched by colleagues, they are more likely to follow the rules, he observed.

New York State has recently begun singling out operators who perform too many inappropriate procedures, Dr. Brener reported. If this practice cuts into hospital income, the offending operators will hear from hospital administrators, he noted. But the scrutiny may also have an untoward consequence in that some physicians may be tempted to “game the system,” either by not reporting data (making procedures unratable) or by upcoding patients to ACS status.

In the end, Dr. Boden concluded, cardiologists “should be held to a standard of what constitutes best practice, and I think most welcome that. We need to police ourselves before [practice] becomes mandated by bureaucrats or other nonphysicians.”

2. Spertus J, Chan P. The need to improve the appropriate use of coronary revascularization: Challenges and opportunities. J Am Coll Cardiol. 2012;59:1877-1880.

Related Stories:

• New Revascularization Appropriateness Criteria Feature PCI Upgrades
• Most Acute PCIs Justified, But Nonacute Procedures Called into Question
• Paper Sparks Renewed Discussion on Appropriate Use of PCI

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