Finding the Optimum in the Use of Elective Percutaneous Coronary Intervention

Evaluating Underuse

While potential underuse of PCI has been described for acute indications [17–22], study of underuse of PCI for elective indications is more challenging. Population data on the effect of underuse of elective PCI on patient symptom burden, functional status, and quality of life is lacking.

A population-based study from Australia highlights the potential importance of underuse in the care of patients with stable coronary disease. This study assessed symptom burden among patients with chronic stable angina using the Seattle Angina Questionnaire and included patients cared for by 207 primary care practitioners [32]. The authors noted that there was considerable variation in patient symptom burden between practices, with 14% of practices having no patients with more than 1 episode of angina per week and 18% of clinics having more than half of enrolled patients with at least 1 episode of angina per week. The authors postulate that this variability may be due to differences among providers in the identification and management of angina, including using PCI to minimize symptom burden.

In the Ko study mentioned earlier, the AUC was used to examine potential underuse of coronary revascularization procedures. In this study, they analyzed the association between AUC ratings and outcomes in patients undergoing diagnostic coronary angiography [30]. Of patients considered “appropriate” for revascularization following completion of diagnostic angiography, only 69% underwent revascularization. However, the clinical aspects that influence the decision to proceed with revascularization may not be fully captured in this study. Thus, the true degree of underuse of PCI remains elusive.

In summary, the relative lack of data that would allow for the assessment of underuse of elective PCI is an important quality concern. Health systems should work to systematically capture patient-reported health status, including symptom burden data, to identify inadequate symptom control and potential underuse of procedural care for CAD.

Facilitating Optimal Use

In current practice, the AUC hold promise to minimize the overuse of elective PCI. This likely involves addressing processes occurring upstream of the cardiac catheterization lab, including employing systems to ensure that procedures are avoided in patients who are unlikely to benefit (eg, asymptomatic, low ischemic burden) ( Figure 3 ) [33]. Studying hospitals that already have low rates of inappropriate PCI may inform the design and dissemination of strategies that will help improve patient selection at hospitals with higher rates. Although professional organizations have developed tools intended to facilitate appropriateness evaluation at the point-of-care [34], the use of these tools are likely to be sporadic without greater integration into the health care delivery system. Further, these applications are currently limited to determination of appropriateness of PCI after completion of the diagnostic coronary angiogram. Identifying processes prior to catheterization that contribute to PCI appropriateness may also streamline appropriate ad hoc PCI, as the need to reassess appropriateness after the diagnostic angiogram may be mitigated.

Significant barriers exist to the application of the AUC for determination of procedural underuse. As described above, we lack adequate data to ascertain gaps in symptom management that could be mitigated by proper use of PCI. Further study of symptom burden in populations of patients with coronary artery disease is needed. This may help in the identification of patient populations whose symptom burden may warrant consideration of invasive coronary procedures, including coronary angiography and PCI.