From the VA Eastern Colorado Health Care System, University of Colorado School of Medicine, and the Colorado Cardiovascular Outcomes Research Group, Denver and Aurora, CO.
Abstract
Objective: To review the use of elective percutaneous coronary intervention (PCI), evaluate what is currently known about elective PCI in the context of appropriate use criteria, and offer insight into next steps to optimize the use of elective PCI to achieve high-quality care.
Methods: Review of the scientific literature, appropriate use criteria, and professional society guidelines relevant to elective PCI.
Results: Recent studies have demonstrated as many as 1 in 6 elective PCIs are inappropriate as determined by appropriate use criteria. These inappropriate PCIs are not anticipated to benefit patients and result in unnecessary patient risk and cost. While these studies are consistent with regard to overuse of elective PCI, less is known about potential underuse of PCI for elective indications. We lack health status data on populations of ischemic heart disease patients to inform PCI underuse that may contribute to patient symptom burden, functional status, and quality of life. Optimal use of PCI will be attained with longitudinal capture of patient-reported health status, study of factors contributing to overuse and underuse, refinement of the appropriate use criteria with particular focus on patient-centered measures, and incorporation of patient preference and shared decision making into appropriateness evaluation tools.
Conclusion: The use of elective PCI is less than optimal in current clinical practice. Continued effort is needed to ensure elective PCI is targeted to patients with anticipated benefit and use of the procedure is aligned with patient preferences.
Providing the right care to the right patient at the right time is essential to the practice of high-quality care. Reducing overuse of health care services is part of this equation, and initiatives to reduce inappropriate use and to encourage physicians and patients to “choose wisely” have been introduced [1]. One procedure that is being examined with a focus on appropriateness is percutaneous coronary intervention (PCI). This procedure is common (nearly 1 million inpatient PCI procedures performed in 2010), presents risks to the patient, and is expensive (attributable cost approximately $10 billion in 2010) [2,3]. While the clinical benefit of PCI in acute settings such as ST-segment elevation myocardial infarction is well established [4], the benefit of PCI in nonacute (elective) settings is less robust [5–7]. Prior studies have demonstrated PCI for stable ischemic heart disease does not result in mortality benefit [6]. Furthermore, PCI as an initial strategy for symptom relief of stable angina may offer little benefit relative to medications alone [5]. Given that PCI is common, costly, and associated with both short- and long-term risks [8,9], ensuring this therapy is provided to the right patient at the right time is important.
In 2009, appropriate use criteria (AUC) were developed by 6 professional organizations to support the rational and judicious use of PCI [10]; a focused update was published in 2012 [11]. In this review, we discuss the recommendations for appropriate use and their application and offer thoughts on next steps to optimize the use of elective PCI as part of high-quality care.
