Coronary Stents and Elective PCI Rates Vary By Hospital

Steven M. Bradley, MD, MPH Veterans Affairs Eastern Colorado Health CareSystem Denver, Colorado MedicalResearch.com Interview with
Steven M. Bradley, MD, MPH
Veterans Affairs, Eastern Colorado Health CareSystem
Denver, Colorado

Medical Research: What are the main findings of the study?

Dr. Bradley: In 539 hospitals participating in the CathPCI Registry that performed elective coronary angiography on more than 500,000 patients, 22% of patients were asymptomatic at the time of coronary angiography. We observed marked variation in the hospital rate of angiography performed in asymptomatic patients, ranging from 0.2% to 66.5%, suggesting broad variation in the quality of patient selection for coronary angiography across hospitals. Additionally, hospitals with higher rates of asymptomatic patients at diagnostic angiography also had higher rates of inappropriate PCI, due to greater use of PCI in asymptomatic patients. These findings suggest that patient selection for diagnostic angiography is associated with the quality of patient selection for PCI as determined by Appropriate Use Criteria. By addressing patient selection upstream of the catheterization laboratory, we may improve on the optimal use of both angiography and PCI.

Medical Research: Were any of the findings unexpected?

Dr. Bradley: Strategies to improve the appropriate use of PCI have emphasized the role of the interventional cardiologist by ensuring that revascularization is warranted after completion of the diagnostic angiogram, particularly when PCI is considered in the same session (i.e. ad hoc PCI). However, this approach fails to consider the potential importance of patient selection for diagnostic coronary angiography—an invasive procedure requested by a range of provider types and specialties. Our study highlights the importance of patient selection processes prior to the cardiac cath lab to ensure the optimal use of both coronary angiography and PCI.

Medical Research: What should clinicians and patients take away from your report?

Dr. Bradley: These findings suggest marked variation in the quality of patient selection for diagnostic coronary angiography by hospital. Furthermore, the quality of patient selection for angiography appears related to the quality of PCI. Both angiography and PCI have small, but real clinical risk, and both procedures have significant cost. Optimizing patient selection for coronary angiography may reduce unnecessary patient risk and cost from both diagnostic coronary angiography and PCI.

Citation:

Patient Selection for Diagnostic Coronary Angiography and Hospital-Level Percutaneous Coronary Intervention Appropriateness: Insights From the National Cardiovascular Data Registry

Steven M. Bradley MD, MPH, John A. Spertus MD, MPH, Kevin F. Kennedy MS, Brahmajee K. Nallamothu MD, MPH, Paul S. Chan MD, MSc, Manesh R. Patel MD, Chris L. Bryson MD, MS, David J. Malenka MD, John S. Rumsfeld MD, PhD

JAMA Intern Med. 2014;174(10):-. doi:10.1001/jamainternmed.2014.390