Finding the Optimum in the Use of Elective Percutaneous Coronary Intervention

Application of the AUC to clinical practice has highlighted potential overuse of PCI ( Table). The first report came from applying the AUC to the National Cardiovascular Data Registry (NCDR) CathPCI Registry [26]. In this study of more than 500,000 PCIs from over 1000 facilities across the country, the authors found that PCIs performed in the acute setting (STEMI, NSTEMI, and high-risk unstable angina) were almost uniformly classified as appropriate. However, for nonacute (elective) PCI, application of the AUC resulted in the classification of 50% as appropriate, 38% as uncertain, and 12% as inappropriate. The majority of patients who received inappropriate PCI had a low-risk stress test (72%) or were asymptomatic (54%). Additionally, 96% of patients who received PCI classified as inappropriate had not been given a trial of adequate anti-anginal therapy. This analysis was supported by subsequent analyses of 2 other state-specific registries (New York and Washington), which found similar rates of PCI for nonacute indications rated as inappropriate [27,28]. Additionally, all 3 studies showed wide facility-level variation in the percentage of appropriate and inappropriate PCI for elective indications.

These studies also highlight a gap in preprocedural care. The anticipated benefit of elective PCI is related to patient symptom burden, adequacy of anti-anginal therapy, and ischemic risk as determined by noninvasive stress testing. However, 30% to 50% of patients undergo elective PCI without evidence of preprocedural stress testing. Attempts are being made to address this gap with the recent release of PCI performance measures [29]. These performance measures, intended for cardiac catheterization labs, include comprehensive documentation of the indication for PCI, which is central to determination of appropriateness. This integration of procedural indication into a performance measure marks the first such occurrence in cardiology.

As documentation of procedural indication and appropriateness have become part and parcel of assessing quality of care, concerns about “gaming” have become more pertinent. Providers who perform PCI could potentially enhance the appearance of appropriateness by overstating the clinical symptom burden or stress test findings. The incorporation of validated, patient-centered health status questionnaires along with data audit programs have been proposed as measures to prevent this type of abuse. Addressing quality gaps in preprocedural assessment and documentation is critical to optimizing use of elective PCI [28].

The apparent overuse of PCI for elective indications may be a reflection of our fragmented, fee-for-service health care delivery system. However, recent studies challenge these assumptions. In a Canadian study, Ko et al found that 18% of elective PCIs were classified as inappropriate, a proportion similar to what had been found previously in the United States [30]. In a US study of Medicare beneficiaries, Matlock and colleagues observed a fourfold regional variation in use of elective coronary angiography and PCI in both Medicare fee-for-service and capitated Medicare Advantage beneficiaries [31]. Collectively, these studies suggest barriers to optimal patient selection for invasive coronary procedures in both capitated and fee-for-service health care systems. Without addressing factors that contribute to variation in the absence of fee-for-service incentives, efforts to improve integration and reduce fee-for-service reimbursement may be inadequate to optimize PCI use.