Finding the Optimum in the Use of Elective Percutaneous Coronary Intervention
Journal of Clinical Outcomes Management. 2014 June;21(6)
References
Variation in the Use of PCI
Since 1996, the Dartmouth Atlas of Health Care has documented substantial geographic variation in health care utilization and spending in the United States [12]. This variation includes a 10-fold difference in the use of PCI across geographic regions [13] ( Figure 1 ). Several studies have suggested that much of this variation reflects overuse. For example, in a cohort study of patients with acute myocardial infarction, patients who lived in regions with lower health care expenditures were more likely to receive guideline-recommended medications at discharge, had similar access to follow-up care, reported similar functional health status and satisfaction with care, and had lower mortality than patients in high-expenditure regions [14,15]. These findings suggest overuse, as higher healthcare expenditures were not associated with better quality of care or patient outcomes.
Additionally, significant public attention has been focused on the issue of overuse after lay press investigations into community practice patterns. In particular, a case study presented in the New York Times highlighted the community of Elyria, Ohio, which was found to have a PCI rate that was 4 times the national average [16]. This investigation sparked public debate and further focused attention on the issue of overuse of elective PCI. Conversely, others have pointed to data that suggest underuse of coronary procedural care, particularly among women and racial and ethnic minorities [17–22].
Appropriate Use Criteria
Development Methodology
AUC for PCI, which were developed through the collaborative efforts of 6 major cardiovascular professional organizations, are intended to support the effective, efficient, and equitable use of PCI [10,11]. They were developed in response to a growing need to support rational use of cardiovascular procedures as part of high-quality care. The methods of development for the AUC have been described in detail in the criteria publications [10,11]. We briefly review these methods here.
In developing the criteria, a writing group created clinical scenarios for which coronary revascularization might be considered in everyday clinical practice [23] ( Figure 2 ). These clinical scenarios were then presented to a 17-member technical panel, members of which were nominated by national cardiology societies. Technical panel members then rated the appropriateness of PCI for each scenario based on randomized trial data, clinical practice guidelines, and their expert opinion. For purposes of AUC development, appropriateness was defined as “when the expected benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of life) exceed the expected negative consequences of the procedure [10].”
Panel members first individually assigned ratings to each clinical scenario that ranged from 1 (least appropriate) to 9 (most appropriate). This was followed by an in-person meeting in which technical panel members discussed scenarios for which there was wide variation in appropriateness assessment. After this meeting, technical panel members again assigned ratings for each scenario from 1 to 9. After this second round, the median values for the pooled ratings were used as the appropriateness classification for each scenario. Scenarios with median values of 1–3 were classified as “inappropriate,” 4–6 as “uncertain,” and 7–9 as “appropriate.” A rating of “appropriate” represented clinical scenarios in which the indication is considered generally acceptable and likely to improve health outcomes or survival. A rating of “uncertain” represented clinical scenarios where the indication may be reasonable but more research is necessary to further understand the relative benefits and risks of PCI in this setting. Finally, a rating of “inappropriate” represented clinical scenarios in which the indication is not generally acceptable as it is unlikely to improve health outcomes or survival.
