Appropriateness of percutaneous coronary intervention

Is Complete Revascularisation Mandated for all Patients with Multivessel Coronary Artery Disease?

In multivessel coronary artery disease (MVCAD), myocardial revascularisation can be achieved by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), with complete revascularisation on all diseased coronary segments or with incomplete revascularisation on selectively targeted lesions. Complete revascularisation confers a long-term prognostic benefit, but is associated with a higher rate of periprocedural events compared with incomplete revascularisation. In most patients with MVCAD, the main advantage of CABG over PCI is conferred by the achievement of more extensive revascularisation. According to current international guidelines, PCI is generally preferred in single-vessel disease, low-risk MVCAD or isolated left main disease; whereas CABG is usually recommended in patients with complex two-vessel disease, most patients with three-vessel disease and/or non-isolated left main disease. In patients with MVCAD, the choice on revascularisation modality should depend on a multifactorial evaluation, taking into account not only coronary anatomy, the ischaemic burden, myocardial function, age and the presence of comorbidities, but also the adequacy of myocardial revascularisation.

Application of appropriate use criteria for percutaneous coronary intervention in Japan

The aim of this review was to summarize the concept of appropriate use criteria (AUC) regarding percutaneous coronary intervention (PCI) and document AUC use and impact on clinical practice in Japan, in comparison with its application in the United States. AUC were originally developed to subjectively evaluate the indications and performance of various diagnostic and therapeutic modalities, including revascularization techniques. Over the years, application of AUC has significantly impacted patient selection for PCI in the United States, particularly in non-acute settings. After the broad implementation of AUC in 2009, the rate of inappropriate PCI decreased by half by 2014. The effect was further accentuated by incorporation of financial incentives (e.g., restriction of reimbursement for inappropriate procedures). On the other hand, when the United States-derived AUC were applied to Japanese patients undergoing elective PCI from 2008 to 2013, about one-third were classified as inappropriate, largely due to the perception gap between American and Japanese experts. For example, PCI for low-risk non-left atrial ascending artery lesion was more likely to be classified as appropriate by Japanese standards, and anatomical imaging with coronary computed tomography angiography was used relatively frequently in Japan, but no scenario within the current AUC includes this modality. To extrapolate the current AUC to Japan or any other region outside of the United States, these local discrepancies must be taken into consideration, and scenarios should be revised to reflect contemporary practice. Understanding the concept of AUC as well as its perception gap between different counties will result in the broader implementation of AUC, and lead to the quality improvement of patients’ care in the field of coronary intervention.

Public Reporting of Mortality Rates for Hospitalized Medicare Patients and Trends in Mortality for Reported Conditions

BACKGROUND

Public reporting is seen as a powerful quality improvement tool, but data to support its efficacy are limited. The Centers for Medicare & Medicaid Services' Hospital Compare program initially reported process metrics only but started reporting mortality rates for acute myocardial infarction, heart failure, and pneumonia in 2008.

OBJECTIVE

To determine whether public reporting of mortality rates was associated with lower mortality rates for these conditions among Medicare beneficiaries.

DESIGN

For 2005 to 2007, process-only reporting was considered; for 2008 to 2012, process and mortality reporting was considered. Changes in mortality trends before and during reporting periods were estimated by using patient-level hierarchical modeling. Nonreported medical conditions were used as a secular control.

SETTING

U.S. acute care hospitals.

PARTICIPANTS

20 707 266 fee-for-service Medicare beneficiaries hospitalized from January 2005 through November 2012.

MEASUREMENTS

30-day risk-adjusted mortality rates.

RESULTS

Mortality rates for the 3 publicly reported conditions were changing at an absolute rate of -0.23% per quarter during process-only reporting, but this change slowed to a rate of -0.09% per quarter during process and mortality reporting (change, 0.13% per quarter; 95% CI, 0.12% to 0.14%). Mortality for nonreported conditions was changing at -0.17% per quarter during process-only reporting and slowed slightly to -0.11% per quarter during process and mortality reporting (change, 0.06% per quarter; CI, 0.05% to 0.07%).

LIMITATION

Administrative data may have limited ability to account for changes in patient complexity over time.

CONCLUSION

Changes in mortality trends suggest that reporting in Hospital Compare was associated with a slowing, rather than an improvement, in the ongoing decline in mortality among Medicare patients.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute.

The transition to value-based care

Delivery of medical care is evolving rapidly worldwide. Over the past several years in the USA, there has been a rapid shift in reimbursement from a simple fee-for-service model to more complex models that attempt to link payment to quality and value. Change in any large system can be difficult, but with medicine, the transition to a value-based system has been particularly hard to implement because both quality and cost are difficult to quantify. Professional societies and other medical groups are developing different programs in an attempt to define high value care. However, applying a national standard of value for any treatment is challenging, since value varies from person to person, and the individual benefit must remain the central tenet for delivering best patient-centered medical care. Regardless of the specific operational features of the rapidly changing healthcare environment, physicians must first and foremost always remain patient advocates.

Precision test for precision medicine: opportunities, challenges and perspectives regarding pre-eclampsia as an intervention window for future cardiovascular disease

Hypertensive disorders of pregnancy (HDP) comprise a spectrum of syndromes that range in severity from gestational hypertension and pre-eclamplsia (PE) to eclampsia, as well as chronic hypertension and chronic hypertension with superimposed PE. HDP occur in 2% to 10% of pregnant women worldwide, and impose a substantial burden on maternal and fetal/infant health. Cardiovascular disease (CVD) is the leading cause of death in women. The high prevalence of non-obstructive coronary artery disease and the lack of an efficient diagnostic workup make the identification of CVD in women challenging. Accumulating evidence suggests that a previous history of PE is consistently associated with future CVD risk. Moreover, PE as a maladaptation to pregnancy-induced hemodynamic and metabolic stress may also be regarded as a "precision" testing result that predicts future cardiovascular risk. Therefore, the development of PE provides a tremendous, early opportunity that may lead to changes in maternal and infant future well-being. However, the underlying pathogenesis of PE is not precise, which warrants precision medicine-based approaches to establish a more precise definition and reclassification. In this review, we proposed a stage-specific, PE-targeted algorithm, which may provide novel hypotheses that bridge the gap between Big Data-generating approaches and clinical translational research in terms of PE prediction and prevention, clinical treatment, and long-term CVD management.

Applying appropriate-use criteria to cardiac revascularisation in India

OBJECTIVES

The high prevalence of coronary heart disease and dramatic growth of cardiac interventions in India motivate an evaluation of the appropriateness of coronary revascularisation procedures in India. Although, appropriate-use criteria (AUC) have been used to analyse the appropriateness of cardiovascular care in the USA, they are yet to be applied to care in India. In our study, we apply AUC to cardiac care in Karnataka, India, compare our results to international applications of AUC, and suggest ways to improve the appropriateness of care in India.

SETTING

Data were collected from the Vajpayee Arogyashree Scheme, a government-sponsored health insurance scheme in Karnataka, India. These data were collected as part of the preauthorisation process for cardiac procedures.

PARTICIPANTS

The final data included a random sample of 600 patients from 28 hospitals in Karnataka, who obtained coronary artery bypass grafting or percutaneous coronary intervention between 1 October 2014 and 31 December 2014.

PRIMARY AND SECONDARY OUTCOME MEASURES

We obtained our primary baseline results using a random imputation simulation to fill in missing data. Our secondary outcome measure was a best case-worst case scenario where missing data were filled to give the lowest or highest number of appropriate cases.

RESULTS

Of the cases, 86.7% (CI 0.837% to 0.892%) were deemed appropriate, 3.65% (CI 0.023% to 0.055%) were inappropriate and 9.63% (CI 0.074% to 0.123%) were uncertain.

CONCLUSIONS

The vast majority of cardiac revascularisation procedures performed on beneficiaries of a government-sponsored insurance programme in India were found to be appropriate. These results meet or exceed levels of appropriate use of cardiac care in the USA.

Effect of angina under-recognition on treatment in outpatients with stable ischaemic heart disease

AIMS

Almost a third of outpatients with chronic coronary artery disease (CAD) report having angina in the prior month, which is frequently under-recognized by their cardiologists. Whether under-recognition is associated with less treatment escalation to control angina, and potential underuse of treatment, is unknown.

METHODS AND RESULTS

Patients with CAD from 25 US cardiology outpatient practices completed the Seattle Angina Questionnaire (SAQ) prior to their clinic visit, and angina was categorized as daily, weekly, monthly and no angina. Cardiologists (n=155) independently quantified patients' angina, blinded to patients' SAQ scores. Under-recognition was defined as the physician reporting a lower category of angina frequency than the patient. Among 1257 patients with CAD, 411 reported angina in the past month, of whom 178 (43.3%) patients were under-recognized. Treatment escalation-defined as intensification (up-titration or addition) of antianginal medications, referral for diagnostic testing or revascularization, or hospital admission-occurred in 106 (25.8%) patients with angina. Patients with under-recognized angina were less likely to get treatment escalation than patients whose angina was appropriately recognized (8.4% vs 39.1%, P<0.001). In a hierarchical multivariable logistic regression model adjusting for demographic and clinical characteristics, as well as the burden of angina, under-recognition remained strongly associated with a lack of treatment escalation (adjusted OR 0.10, 95% CI 0.04-0.21, P<0.001).

CONCLUSIONS

Under-recognition of angina in cardiology outpatient practices is associated with less aggressive treatment escalation and may lead to poorer angina control. Standardizing clinical recognition of angina using validated tools could reduce under-recognition of angina, facilitate treatment, and potentially improve outcomes.

Practice-Level Variation in Outpatient Cardiac Care and Association With Outcomes

BACKGROUND

Utilization of cardiac services varies across regions and hospitals, yet little is known regarding variation in the intensity of outpatient cardiac care across cardiology physician practices or the association with clinical endpoints, an area of potential importance to promote efficient care.

METHODS AND RESULTS

We included 7 160 732 Medicare beneficiaries who received services from 5635 cardiology practices in 2012. Beneficiaries were assigned to practices providing the plurality of office visits, and practices were ranked and assigned to quartiles using the ratio of observed to predicted annual payments per beneficiary for common cardiac services (outpatient intensity index). The median (interquartile range) outpatient intensity index was 1.00 (0.81-1.24). Mean payments for beneficiaries attributed to practices in the highest (Q4) and lowest (Q1) quartile of outpatient intensity were: all cardiac payments (Q4 $1272 vs Q1 $581; ratio, 2.2); cardiac catheterization (Q4 $215 vs Q1 $64; ratio, 3.4); myocardial perfusion imaging (Q4 $253 vs Q1 $83; ratio, 3.0); and electrophysiology device procedures (Q4 $353 vs Q1 $142; ratio, 2.5). The adjusted odds ratios (95% CI) for 1 incremental quartile of outpatient intensity for each outcome was: cardiac surgical/procedural hospitalization (1.09 [1.09, 1.10]); cardiac medical hospitalization (1.00 [0.99, 1.00]); noncardiac hospitalization (0.99 [0.99, 0.99]); and death at 1 year (1.00 [0.99, 1.00]).

CONCLUSION

Substantial variation in the intensity of outpatient care exists at the cardiology practice level, and higher intensity is not associated with reduced mortality or hospitalizations. Outpatient cardiac care is a potentially important target for efforts to improve efficiency in the Medicare population.

Predictors of Medical Management in Patients Undergoing Elective Cardiac Catheterization for Chronic Ischemic Heart Disease

BACKGROUND

Compared with medical therapy, percutaneous coronary intervention (PCI) does not reduce mortality or myocardial infarction in patients with stable angina. Therefore, PCI should be guided by refractory anginal symptoms and not just lesion characteristics.

HYPOTHESIS

We hypothesized that angiographic lesion characteristics and stress test results would have a greater role in the decision to proceed with PCI than would symptom severity.

METHODS

We performed a retrospective cohort study of patients undergoing elective cardiac catheterization and possible PCI at an academic medical center. Anginal symptoms, optimal medical therapy, antianginal therapy, stress test results, and angiographic lesions (including American College of Cardiology/American Heart Association [ACC/AHA] lesion type) were analyzed. Logistic regression was used to determine predictors of medical management among patients not referred for coronary artery bypass surgery.

RESULTS

Of the 207 patients with obstructive lesions amenable to PCI, 163 underwent PCI and 44 were referred to medical therapy. In the multivariable logistic model, the following variables were associated with medical management: advancing age (odds ratio [OR] per 1 year: 0.94, 95% confidence interval [CI]: 0.91-0.98), chronic kidney disease (OR: 0.23, 95% CI: 0.06-0.95), distal location (OR: 0.21, 95% CI: 0.09-0.48), and ACC/AHA type C lesion (OR: 0.08, 95% CI: 0.03-0.22). There was no association with sex, race, symptoms, optimal medical therapy, maximal antianginal therapy, referral status, or type of interventional cardiologist (academic vs private practice).

CONCLUSIONS

For patients undergoing cardiac catheterization for stable angina, the decision to proceed to PCI vs medical management appears to depend largely on patient and angiographic characteristics, but not on symptoms or ischemia. Distal and high-risk lesions (ACC/AHA type C) are more often referred for medical therapy.

Conservative versus invasive stable ischemic heart disease management strategies: what do we plan to learn from the ISCHEMIA trial?

Over the past decade, landmark randomized clinical trials comparing initial management strategies in stable ischemic heart disease (SIHD) have demonstrated no significant reduction in ‘hard’ end points (all-cause mortality, cardiac death or myocardial infarction) with one strategy versus another. The main advantage derived from early revascularization is improved short-term quality of life. Nonetheless, questions remain regarding how best to manage SIHD patients, such as whether a high-risk subgroup can be identified that may experience a survival or myocardial infarction benefit from early revascularization, and if not, when should diagnostic catheterization and revascularization be performed. The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial is designed to address these questions by randomizing SIHD patients with at least moderate ischemia to an initial conservative strategy of optimal medical therapy or an initial invasive strategy of optimal medical therapy plus cardiac catheterization and revascularization.

Noninvasive Cardiac Imaging in Patients with Known and Suspected Coronary Artery Disease: What is in it for the Interventional Cardiologist?

The long-standing coronary artery disease (CAD) paradigm simplified by the discrimination between patients with or without CAD warrants to be revisited by the insightful information provided by noninvasive cardiac imaging, leading to a comprehensive physiopathological assessment rather than a mainly anatomical approach. This review will address (1) the role of non-invasive cardiac imaging for the appropriate selection of stable patients referred to invasive coronary angiography (ICA), and the evolving concept and prognostic implications of myocardial ischemia; (2) the usefulness of computed tomography coronary angiography for the guidance of percutaneous coronary interventions; and (3) the role and potential clinical impact of novel anatomical and functional non-invasive prognostic markers.

Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection, and Appropriateness of Percutaneous Coronary Intervention

IMPORTANCE

Appropriate Use Criteria for Coronary Revascularization were developed to critically evaluate and improve patient selection for percutaneous coronary intervention (PCI). National trends in the appropriateness of PCI have not been examined.

OBJECTIVE

To examine trends in PCI utilization, patient selection, and procedural appropriateness following the introduction of Appropriate Use Criteria.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, longitudinal, cross-sectional analysis of patients undergoing PCI between July 1, 2009, and December 31, 2014, at hospitals continuously participating in the National Cardiovascular Data Registry CathPCI registry over the study period.

MAIN OUTCOMES AND MEASURES

Proportion of nonacute PCIs classified as inappropriate at the patient and hospital level using the 2012 Appropriate Use Criteria for Coronary Revascularization.

RESULTS

A total of 2.7 million PCI procedures from 766 hospitals were included. Annual PCI volume of acute indications was consistent over the study period (377,540 in 2010; 374,543 in 2014), but the volume of nonacute PCIs decreased from 89,704 in 2010 to 59,375 in 2014. Among patients undergoing nonacute PCI, there were significant increases in angina severity (Canadian Cardiovascular Society grade III/IV angina, 15.8% in 2010 and 38.4% in 2014), use of antianginal medications prior to PCI (at least 2 antianginal medications, 22.3% in 2010 and 35.1% in 2014), and high-risk findings on noninvasive testing (22.2% in 2010 and 33.2% in 2014) (P < .001 for all), but only modest increases in multivessel coronary artery disease (43.7% in 2010 and 47.5% in 2014, P < .001). The proportion of nonacute PCIs classified as inappropriate decreased from 26.2% (95% CI, 25.8%-26.6%) to 13.3% (95% CI, 13.1%-13.6%), and the absolute number of inappropriate PCIs decreased from 21,781 to 7921. Hospital-level variation in the proportion of PCIs classified as inappropriate persisted over the study period (median, 12.6% [interquartile range, 5.9%-22.9%] in 2014).

CONCLUSIONS AND RELEVANCE

Since the publication of the Appropriate Use Criteria for Coronary Revascularization in 2009, there have been significant reductions in the volume of nonacute PCI. The proportion of nonacute PCIs classified as inappropriate has declined, although hospital-level variation in inappropriate PCI persists.

Assessment of inpatient multimodal cardiac imaging appropriateness at large academic medical centers

Background

Responding to concerns regarding the growth of cardiac testing, the American College of Cardiology Foundation (ACCF) published Appropriate Use Criteria (AUC) for various cardiac imaging modalities. Single modality cardiac imaging appropriateness has been reported but there have been no studies assessing the appropriateness of multiple imaging modalities in an inpatient environment.

Methods

A retrospective study of the appropriateness of cardiac tests ordered by the inpatient General Internal Medicine (GIM) and Cardiology services at three Canadian academic hospitals was conducted over two one-month periods. Cardiac tests characterized were transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), single-photon emission tomography myocardial perfusion imaging (SPECT), and diagnostic cardiac catheterization.

Results

Overall, 553 tests were assessed, of which 99.8 % were classifiable by AUC. 91 % of all studies were categorized as appropriate, 4 % may be appropriate and 5 % were rarely appropriate. There were high rates of appropriate use of all modalities by GIM and Cardiology throughout. Significantly more appropriate diagnostic catheterizations were ordered by Cardiology than GIM (93 % vs. 82 %, p = <0.01). Cardiology ordered more appropriate studies overall (94 % vs. 88 %, p = 0.03) but there was no difference in the rate of rarely appropriate studies (3 % vs. 6 %, p = 0.23).

Conclusion

The ACCF AUC captured the vast majority of clinical scenarios for multiple cardiac imaging modalities in this multi-centered study on Cardiology and GIM inpatients in the acute care setting. The rate of appropriate ordering was high across all imaging modalities. We recommend further work towards improving appropriate utilization of cardiac imaging resources focus on the out-patient setting.

The Concept of Functional Percutaneous Coronary Intervention: Why Physiologic Lesion Assessment Is Integral to Coronary Angiography

The gold standard for assessing the severity of coronary stenoses has been coronary angiography. However, multicenter randomized clinical trials have demonstrated that treatment decisions based on angiography alone do not guarantee benefit to patients. Fractional flow reserve provides physiologic lesion assessment of coronary stenoses. The use of physiology improves clinical outcomes when used for decision making for coronary revascularization. In the era of increased scrutiny of appropriateness of cardiac catheterization and percutaneous coronary intervention, the use of physiologic assessment of the severity of coronary stenoses should be considered an integral adjunct to the anatomic evaluation provided by the coronary angiogram.

Association of Physician Certification in Interventional Cardiology With In-Hospital Outcomes of Percutaneous Coronary Intervention

BACKGROUND

The value of American Board of Internal Medicine certification has been questioned. We evaluated the Association of Interventional Cardiology certification with in-hospital outcomes of patients undergoing percutaneous coronary intervention (PCI) in 2010.

METHODS AND RESULTS

We identified physicians who performed ≥10 PCIs in 2010 in the CathPCI Registry and determined interventional cardiology (ICARD) certification status using American Board of Internal Medicine data. We compared in-hospital outcomes of patients treated by certified and noncertified physicians using hierarchical multivariable models adjusted for differences in patient characteristics and PCI volume. Primary end points were all-cause in-hospital mortality and bleeding complications. Secondary end points included emergency coronary artery bypass grafting, vascular complications, and a composite of any adverse outcome. With 510,708 PCI procedures performed by 5175 physicians, case mix and unadjusted outcomes were similar among certified and noncertified physicians. The adjusted risks of in-hospital mortality (odds ratio, 1.10; 95% confidence interval, 1.02-1.19) and emergency coronary artery bypass grafting (odds ratio, 1.32; 95% confidence interval, 1.12-1.56) were higher in the non-ICARD-certified group, but the risks of bleeding and vascular complications and the composite end point were not statistically significantly different between groups.

CONCLUSIONS

We did not observe a consistent association between ICARD certification and the outcomes of PCI procedures. Although there was a significantly higher risk of mortality and emergency coronary artery bypass grafting in patients treated by non-ICARD-certified physicians, the risks of vascular complications and bleeding were similar. Our findings suggest that ICARD certification status alone is not a strong predictor of patient outcomes and indicate a need to enhance the value of subspecialty certification.

Percutaneous Coronary Intervention Utilization and Appropriateness across the United States

Background

Substantial geographic variation exists in percutaneous coronary intervention (PCI) use across the United States. It is unclear the extent to which high PCI utilization can be explained by PCI for inappropriate indications. The objective of this study was to examine the relationship between PCI rates across regional healthcare markets utilizing hospital referral regions (HRRs) and PCI appropriateness.

Methods

The number of PCI procedures in each HRR was obtained from the 2010 100% Medicare limited data set. HRRs were divided into quintiles of PCI utilization with increasing rates of utilization progressing to quintile 5. NCDR CathPCI Registry^® data were used to evaluate patient characteristics, appropriate use criteria (AUC), and outcomes across the HRR quintiles defined by PCI utilization with the study population restricted to HRRs where ≥ 80% of the PCIs were performed at institutions participating in the registry. PCI appropriateness was defined using 2012 AUC by the American College of Cardiology (ACC)/American Heart Association (AHA)/The Society for Cardiovascular Angiography and Interventions (SCAI).

Results

Our study cohort comprised of 380,981 patients treated at 178 HRRs. Mean PCI rates per 1,000 increased from 4.6 in Quintile 1 to 10.8 in Quintile 5. The proportion of non-acute PCIs was 27.7% in Quintile 1 increasing to 30.7% in Quintile 5. Significant variation (p < 0.001) existed across the quintiles in the categorization of appropriateness across HRRs of utilization with more appropriate PCI in lower utilization areas (Appropriate: Q1, 76.53%, Q2, 75.326%, Q3, 75.23%, Q4, 73.95%, Q5, 72.768%; Inappropriate: Q1 3.92%, Q2 4.23%, Q3 4.32%, Q4 4.35%, Q5 4.05%; Uncertain: Q1 8.29%, Q2 8.84%, Q3 8.08%, Q4 9.01%, Q5 8.93%; Not Mappable: Q1 11.26%, Q2 11.67%, Q3 12.37%, Q4 12.69%, Q5 14.34%). There was no difference in risk-adjusted mortality across quintiles of PCI utilization.

Conclusions

Geographic regions with lower PCI rates have a higher proportion of PCIs performed for appropriate indications. Areas that perform more PCIs also appear to perform more elective PCI and many could not be mapped by the AUC.

Validation of the appropriate use criteria for percutaneous coronary intervention in patients with stable coronary artery disease (from the COURAGE trial)

Establishing the validity of appropriate use criteria (AUC) for percutaneous coronary intervention (PCI) in the setting of stable ischemic heart disease can support their adoption for quality improvement. We conducted a post hoc analysis of 2,287 Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial patients with stable ischemic heart disease randomized to PCI with optimal medical therapy (OMT) or OMT alone. Within appropriateness categories, we compared rates of death, myocardial infarction, revascularization subsequent to initial therapy, and angina-specific health status as determined by the Seattle Angina Questionnaire in patients randomized to PCI + OMT to those randomized to OMT alone. A total of 1,987 patients (87.9%) were mapped to the 2012 publication of the AUC, with 1,334 (67.1%) classified as appropriate, 551 (27.7%) uncertain, and 102 (5.1%) as inappropriate. There were no significant differences between PCI and OMT alone in the rate of mortality and myocardial infarction by appropriateness classification. Rates of revascularization were significantly lower in patients initially receiving PCI + OMT who were classified as appropriate (hazard ratio 0.65; 95% confidence interval 0.53 to 0.80; p <0.001) or uncertain (hazard ratio 0.49; 95% confidence interval 0.32 to 0.76; p = 0.001). Furthermore, among patients classified as appropriate by the AUC, Seattle Angina Questionnaire scores at 1 month were better in the PCI-treated group compared with the medical therapy group (80 ± 23 vs 75 ± 24 for angina frequency, 73 ± 24 vs 68 ± 24 for physical limitations, and 68 ± 23 vs 60 ± 24 for quality of life; all p <0.01), with differences generally persisting through 12 months. In contrast, health status scores were similar throughout the first year of follow-up in PCI + OMT patients compared with OMT alone in patients classified as uncertain or inappropriate. In conclusion, these findings support the validity of the AUC in efforts to improve health care quality through optimal use of PCI.

Determinants of variations in initial treatment strategies for stable ischemic heart disease

BACKGROUND

The ratio of revascularization to medical therapy (referred to herein as the revascularization ratio) for the initial treatment of stable ischemic heart disease varies considerably across hospitals. We conducted a comprehensive study to identify patient, physician and hospital factors associated with variations in the revascularization ratio across 18 cardiac centres in the province of Ontario. We also explored whether clinical outcomes differed between hospitals with high, medium and low ratios.

METHODS

We identified all patients in Ontario who had stable ischemic heart disease documented by index angiography performed between Oct. 1, 2008, and Sept. 30, 2011, at any of the 18 cardiac centres in the province. We classified patients by initial treatment strategy (medical therapy or revascularization). Hospitals were classified into equal tertiles based on their revascularization ratio. The primary outcome was all-cause mortality. Patient follow-up was until Dec. 31, 2012. Hierarchical logistic regression models identified predictors of revascularization. Multivariable Cox proportional hazards models, with a time-varying covariate for actual treatment received, were used to evaluate the impact of the revascularization ratio on clinical outcomes.

RESULTS

Variation in revascularization ratios was twofold across the hospitals. Patient factors accounted for 67.4% of the variation in revascularization ratios. Physician and hospital factors were not significantly associated with the variation. Significant patient-level predictors of revascularization were history of smoking, multivessel disease, high-risk findings on noninvasive stress testing and more severe symptoms of angina (v. no symptoms). Treatment at hospitals with a high revascularization ratio was associated with increased mortality compared with treatment at hospitals with a low ratio (hazard ratio 1.12, 95% confidence interval 1.03-1.21).

INTERPRETATION

Most of the variation in revascularization ratios across hospitals was warranted, in that it was driven by patient factors. Nonetheless, the variation was associated with potentially important differences in mortality.

Fundamentals in clinical coronary physiology: why coronary flow is more important than coronary pressure

Wide attention for the appropriateness of coronary stenting in stable ischaemic heart disease (IHD) has increased interest in coronary physiology to guide decision making. For many, coronary physiology equals the measurement of coronary pressure to calculate the fractional flow reserve (FFR). While accumulating evidence supports the contention that FFR-guided revascularization is superior to revascularization based on coronary angiography, it is frequently overlooked that FFR is a coronary pressure-derived estimate of coronary flow impairment. It is not the same as the direct measures of coronary flow from which it was derived, and which are critical determinants of myocardial ischaemia. This review describes why coronary flow is physiologically and clinically more important than coronary pressure, details the resulting limitations and clinical consequences of FFR-guided clinical decision making, describes the scientific consequences of using FFR as a gold standard reference test, and discusses the potential of coronary flow to improve risk stratification and decision making in IHD.

What ails the practice of medicine: the Atlas has shrugged

Health-care providers are currently facing a huge challenge. At one end they are expending a huge amount of time and energies on health-care delivery including time spent on upgradation of their knowledge and skills (to remain abreast with the field and be able to provide state-of-art patient care), sometimes even at the expense of themselves and their families. On the other hand they are not receiving adequate re-imbursement for their efforts. To compound the problem several "traders" have entered the profession who are well adept in the materialistic approach abandoning the ethics (which currently happens to be the flavor of society in general), giving a bad name to the whole profession and causing severe grief, embarrassment and even dis-illusion to an average physician. The solution to the problem may lie in weeding out these "black sheep" as also realization by the society that the whole profession should not be wrongly labeled, rather a hard toiling and a morally driven practitioner should be given his/her due worth.

Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians

BACKGROUND

Cardiac screening in adults with resting or stress electrocardiography, stress echocardiography, or myocardial perfusion imaging can reveal findings associated with increased risk for coronary heart disease events, but inappropriate cardiac testing of low-risk adults has been identified as an important area of overuse by several professional societies.

METHODS

Narrative review based on published systematic reviews; guidelines; and articles on the yield, benefits, and harms of cardiac screening in low-risk adults.

RESULTS

Cardiac screening has not been shown to improve patient outcomes. It is also associated with potential harms due to false-positive results because they can lead to subsequent, potentially unnecessary tests and procedures. Cardiac screening is likely to be particularly inefficient in adults at low risk for coronary heart disease given the low prevalence and predictive values of testing in this population and the low likelihood that positive findings will affect treatment decisions. In this patient population, clinicians should focus on strategies for mitigating cardiovascular risk by treating modifiable risk factors (such as smoking, diabetes, hypertension, hyperlipidemia, and overweight) and encouraging healthy levels of exercise.

HIGH-VALUE CARE ADVICE

Clinicians should not screen for cardiac disease in asymptomatic, low-risk adults with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging.

The Appropriate Use of Percutaneous Coronary Intervention in Contemporary Clinical Practice

Percutaneous coronary intervention (PCI) is common and generally low risk. Although shown to be of significant benefit in certain clinical situations, especially in the context of acute coronary syndromes, there exist clinical scenarios where PCI has not been shown to be helpful. In these cases, the risk of periprocedural complications as well as longer term issues such as bleeding or stent thrombosis mean that PCI may potentially be harmful. To inform best clinical practice, we now have published recommendations with regards to the Appropriate Use Criteria (AUC) for coronary revascularisation. The goal of the AUC is to guide physician decision-making and future research as well as to label coronary revascularisation more clearly for patients and payors in regards to its expected benefits in certain situations. In this review, we summarise and discuss the more clinically relevant of these AUC, either because they are contentious or of particular relevance to the local context or practice. We conclude that there continue to be situations whereby inappropriate PCIs are performed, and these represent opportunities for quality improvement.

Regional differences in treatment frequency and case-fatality rates in korean patients with acute myocardial infarction using the Korea national health insurance claims database: findings of a large retrospective cohort study

Issues regarding healthcare disparity continue to increase in connection with access to quality care for acute myocardial infarction (AMI), even though the case-fatality rate (CFR) continues to decrease. We explored regional variation in AMI CFRs and examined whether the variation was due to disparities in access to quality medical services for AMI patients. A dataset was constructed from the Korea National Health Insurance Claims Database to conduct a retrospective cohort study of 95,616 patients who were admitted to a hospital in Korea from 2003 to 2007 with AMI. Each patient was followed in the claims database for information about treatment after admission or death. The procedure rate decreased as the region went "down" from Seoul to the county level, whereas the AMI CFR increased as the county level as a function of proximity to the county level (30-day AMI CFRs: Seoul, 16.4%; metropolitan areas, 16.2%, cities; 18.8%, counties, 39.4%). Even after adjusting for covariates, an identical regional variation in the odds of patients receiving treatment services and dying was identified. After adjusting for invasive and medical management variables in addition to earlier covariates, the death risk in the counties remained statistically significantly higher than in Seoul; however, the degree of the difference decreased greatly and the significant differences in metropolitan areas and cities disappeared. Policy interventions are needed to increase access to quality AMI care in county-level local areas because regional differences in the AMI CFR are likely caused by differences in the performance of medical and invasive management among the regions of Korea. Additionally, a public education program to increase the awareness of early symptoms and the necessity of visiting the hospital early should be established as the first priority to improve the outcome of AMI patents, especially in county-level local areas.

Patient selection for diagnostic coronary angiography and hospital-level percutaneous coronary intervention appropriateness: insights from the National Cardiovascular Data Registry

IMPORTANCE

Diagnostic coronary angiography in asymptomatic patients may lead to inappropriate percutaneous coronary intervention (PCI) due to a diagnostic-therapeutic cascade. Understanding the association between patient selection for coronary angiography and PCI appropriateness may inform strategies to minimize inappropriate procedures.

OBJECTIVE

To determine if hospitals that frequently perform coronary angiography in asymptomatic patients, a clinical scenario in which the benefit of angiography is less clear, are more likely to perform inappropriate PCI.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter observational study of 544 hospitals participating in the CathPCI Registry between July 1, 2009, and September 30, 2013.

MAIN OUTCOMES AND MEASURES

Hospital proportion of asymptomatic patients at diagnostic coronary angiography and hospital rate of inappropriate PCI as defined by 2012 appropriate use criteria for coronary revascularization.

RESULTS

Of 1 225 562 patients who underwent elective coronary angiography, 308 083 (25.1%) were asymptomatic. The hospital proportion of angiography among asymptomatic patients ranged from 1.0% to 73.6% (median, 24.7%; interquartile range, 15.9%-35.9%). By hospital quartile of asymptomatic patients at angiography, hospitals with higher rates of asymptomatic patients at angiography had higher median rates of inappropriate PCI (14.8% vs 20.2% vs 24.0 vs 29.4% from lowest to highest quartile, P < .001 for trend). This outcome was attributable to more frequent use of inappropriate PCI in asymptomatic patients at hospitals with higher rates of angiography in asymptomatic patients (5.4% vs 9.9% vs 14.7% vs 21.6% from lowest to highest quartile, P < .001 for trend). Hospitals with higher rates of asymptomatic patients at angiography also had lower rates of appropriate PCI (38.7% vs 33.0% vs 32.3% vs 32.9% from lowest to highest quartile, P < .001 for trend).

CONCLUSIONS AND RELEVANCE

In a national sample of hospitals, performance of coronary angiography in asymptomatic patients was associated with higher rates of inappropriate PCI and lower rates of appropriate PCI. Improving preprocedural risk stratification and thresholds for coronary angiography may be one strategy to improve the appropriateness of PCI.

Development and validation of a short version of the Seattle angina questionnaire

BACKGROUND

Clinical trials and national performance measures increasingly mandate reporting patients' perspectives of their health status: their symptoms, function, and quality of life. Although the Seattle Angina Questionnaire (SAQ) is a validated disease-specific health status instrument for coronary artery disease (CAD) with high test-retest reliability, predictive power, and responsiveness, its use in routine clinical practice has been limited, in part, by its length (19 items).

METHODS AND RESULTS

Using data from 10 408 patients with CAD from 5 multicenter registries, we derived and validated a shortened version of the SAQ (SAQ-7) among patients presenting with stable CAD, undergoing percutaneous coronary intervention, and after acute myocardial infarction. We examined the psychometric properties of the SAQ-7 as compared with the full SAQ. Seven items from the Physical Limitation, Angina Frequency, and Quality of Life domains were identified for the SAQ-7, with high levels of concordance (0.88-1.00) with each original SAQ domain. The SAQ-7 demonstrated good construct validity (compared with Canadian Cardiovascular Society class for angina), with a correlation of 0.62 and 0.38 for patients with stable CAD and undergoing percutaneous coronary intervention, respectively. It was highly reproducible in patients with stable CAD (intraclass correlation, ≥0.78) and exhibited excellent responsiveness in patients after percutaneous coronary intervention (≥18 points in each SAQ domain). Finally, the SAQ-7 was predictive of 1-year mortality and readmission.

CONCLUSIONS

To increase the feasibility of measuring patient-reported outcomes in patients with CAD, we developed and validated a shortened 7-item SAQ instrument for use in clinical trials and routine care.

Appropriate revascularization in stable angina: lessons from the BARI 2D trial

BACKGROUND

The 2012 Guidelines for Diagnosis and Management of Patients with Stable Ischemic Heart Disease recommend intensive antianginal and risk factor treatment (optimal medical management [OMT]) before considering revascularization to relieve symptoms. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial randomized patients with ischemic heart disease and anatomy suitable to revascularization to (1) initial OMT with revascularization if needed or (2) initial revascularization plus OMT and found no difference in major cardiovascular events. Ultimately, however, 37.9% of the OMT group was revascularized during the 5-year follow-up period.

METHODS

Data from the 1192 patients randomized to OMT were analyzed to identify subgroups in which the incidence of revascularization was so high that direct revascularization without a trial period could be justified. Multivariate logistic analysis, Cox regression models of baseline data, and a landmark analysis of participants who did not undergo revascularization at 6 months were constructed.

RESULTS

The models that used only data available at the time of study entry had limited predictive value for revascularization by 6 months or by 5 years; however, the model incorporating severity of angina during the first 6 months could better predict revascularization (C statistic = 0.789).

CONCLUSIONS

With the possible exception of patients with severe angina and proximal left anterior descending artery disease, this analysis supports the recommendation of the 2012 guidelines for a trial of OMT before revascularization. Patients could not be identified at the time of catheterization, but a short period of close follow-up during OMT identified the nearly 40% of patients who underwent revascularization.

Symptoms and angiographic findings of patients undergoing elective coronary angiography without prior stress testing

Many patients undergo elective coronary angiography without preprocedural stress testing that may be suitable if performed in patients with more angina pectoris or more frequently identified obstructive coronary artery disease (CAD). Patients in the National Cardiovascular Data Registry CathPCI Registry undergoing elective coronary angiography from July 2009 to April 2013 were assessed for differences in angina (Canadian Cardiovascular Society [CCS] class) and severity of obstructive CAD in those with and without preprocedural stress testing, stratified by CAD history. Given the large sample size, differences were considered clinically meaningful if the standardized difference (SD) was >10%. Of 790,601 patients without CAD history, 36.9% did not undergo preprocedural stress testing. Compared with patients with preprocedural stress testing, patients without preprocedural stress testing were more frequently angina free (CCS class 0; 28.2% with stress test vs 38.5% without, SD = 14.8%) and had similar rates of obstructive CAD (40.1% with stress test vs 35.7% without, SD = 9.0). Of 449,579 patients with CAD history, 44.2% did not undergo preprocedural stress testing. Patients without preprocedural stress testing reported more angina (CCS class III/IV angina: 17.8% vs 13.4%; SD = 11.3%) but were not more likely to have obstructive CAD (78.7% vs 81.1%; SD = 5.8%) than patients with preprocedural stress testing. In conclusion, approximately 40% of patients undergoing elective coronary angiography did not have preprocedural risk stratification with stress testing. For these patients, the clinical decision to proceed directly to invasive evaluation was not driven primarily by severe angina and did not result in higher detection rates for obstructive CAD.

Myocardial ischemia is a key factor in the management of stable coronary artery disease

Previous studies demonstrated that coronary revascularization, especially percutaneous coronary intervention (PCI), does not significantly decrease the incidence of cardiac death or myocardial infarction in patients with stable coronary artery disease. Many studies using myocardial perfusion imaging (MPI) showed that, for patients with moderate to severe ischemia, revascularization is the preferred therapy for survival benefit, whereas for patients with no to mild ischemia, medical therapy is the main choice, and revascularization is associated with increased mortality. There is some evidence that revascularization in patients with no or mild ischemia is likely to result in worsened ischemia, which is associated with increased mortality. Studies using fractional flow reserve (FFR) demonstrate that ischemia-guided PCI is superior to angiography-guided PCI, and the presence of ischemia is the key to decision-making for PCI. Complementary use of noninvasive MPI and invasive FFR would be important to compensate for each method's limitations. Recent studies of appropriateness criteria showed that, although PCI in the acute setting and coronary bypass surgery are properly performed in most patients, PCI in the non-acute setting is often inappropriate, and stress testing to identify myocardial ischemia is performed in less than half of patients. Also, some studies suggested that revascularization in an inappropriate setting is not associated with improved prognosis. Taken together, the presence and the extent of myocardial ischemia is a key factor in the management of patients with stable coronary artery disease, and coronary revascularization in the absence of myocardial ischemia is associated with worsened prognosis.

IMPLEMENTATION OF EVIDENCE-BASED CLINICAL-AND-MORPHOLOGICAL APPROPRIATE USE CRITERIA FOR CORONARY REVASCULARIZATION IN PATIENTS WITH ACUTE CORONARY SYNDROME IN RUSSIA

Aim. To study possibility of using the evidence-based clinical-andmorphological appropriate use criteria for percutaneous coronary interventions (PCIs) for expert evaluation of high-technology procedures implementation in patients with acute coronary syndrome (ACS) in Russia.

Materials and methods. The appropriateness of performed PCI was assessed in patients with ACS, underwent coronary revascularization. The potential need in PCI was determined in ACS patients refused from coronary revascularization. Assessment was performed with the help of ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update (ACCF 2012). Data from 65,912 ACS patients, containing in Russian ACS Registry (2010–2011) were examined.

Results. ACCF 2012 criteria allow to assess the clinical appropriateness of PCI in 79.2% of patients underwent coronary revascularization and to determine the potential need in PCI in 80.6% of patients, refrained from coronary revascularization. Among ACS patients underwent PCI (n=9147), intervention was appropriate in 68.9% of cases. Inappropriate PCI was revealed in 4.6% of cases. Among patients refrained from PCI (n=56765), coronary revascularization was potentially appropriate in 57.9% of cases.

Conclusion. ACCF 2012 clinical-and-morphological criteria allow to judge on appropriateness of performed PCI and to evaluate the potential need in PCI among the most part of Russian ACS patients. In present study coronary revascularization was appropriate in the majority of ACS patients. It was shown possible to use the evidence-based clinical-andmorphological criteria for expert evaluation of high-technology procedures implementation in Russian ACS patients.

Cost-effectiveness of initial stress cardiovascular MR, stress SPECT or stress echocardiography as a gate-keeper test, compared with upfront invasive coronary angiography in the investigation and management of patients with stable chest pain: mid-term outcomes from the CECaT randomised controlled trial

OBJECTIVES

To compare outcomes and cost-effectiveness of various initial imaging strategies in the management of stable chest pain in a long-term prospective randomised trial.

SETTING

Regional cardiothoracic referral centre in the east of England.

PARTICIPANTS

898 patients (69% man) entered the study with 869 alive at 2 years of follow-up. Patients were included if they presented for assessment of stable chest pain with a positive exercise test and no prior history of ischaemic heart disease. Exclusion criteria were recent infarction, unstable symptoms or any contraindication to stress MRI.

PRIMARY OUTCOME MEASURES

The primary outcomes of this follow-up study were survival up to a minimum of 2 years post-treatment, quality-adjusted survival and cost-utility of each strategy.

RESULTS

898 patients were randomised. Compared with angiography, mortality was marginally higher in the groups randomised to cardiac MR (HR 2.6, 95% CI 1.1 to 6.2), but similar in the single photon emission CT-methoxyisobutylisonitrile (SPECT-MIBI; HR 1.0, 95% CI 0.4 to 2.9) and ECHO groups (HR 1.6, 95% CI 0.6 to 4.0). Although SPECT-MIBI was marginally superior to other non-invasive tests there were no other significant differences between the groups in mortality, quality-adjusted survival or costs.

CONCLUSIONS

Non-invasive cardiac imaging can be used safely as the initial diagnostic test to diagnose coronary artery disease without adverse effects on patient outcomes or increased costs, relative to angiography. These results should be interpreted in the context of recent advances in imaging technology.

TRIAL REGISTRATION

ISRCTN 47108462, UKCRN 3696.

Impact of public reporting and outlier status identification on percutaneous coronary intervention case selection in Massachusetts

OBJECTIVES

This study sought to evaluate the impact of public reporting of hospitals as negative outliers on percutaneous coronary intervention (PCI) case-mix selection.

BACKGROUND

Public reporting of risk-adjusted in-hospital mortality after PCI is intended to improve outcomes. However, public labeling of negative outliers based on risk-adjusted mortality rates may detrimentally affect hospitals' willingness to care for high-risk patients.

METHODS

We used generalized estimating equations to examine expected in-hospital mortality rates for 116,227 PCI patients at all nonfederally funded Massachusetts hospitals performing PCI from 2003 to 2010. The main outcome measure was the change in predicted in-hospital mortality rates per hospital after outlier status identification.

RESULTS

The prevalence-weighted mean expected mortality for all PCI cases during the study period was 1.38 ± 0.36% (5.3 ± 1.96% for all shock or ST-segment elevation myocardial infarction patients, 0.58 ± 0.19% for all not shock, not ST-segment elevation myocardial infarction patients). After public identification as a negative outlier institution, there was an 18% relative reduction (absolute 0.25% reduction) in predicted mortality among PCI patients at outlier institutions (95% confidence interval: -0.04 to -0.46%, p = 0.021) compared with nonoutlier institutions. Throughout the study period, there was an additional 37% relative (0.51% absolute) reduction in the predicted mortality risk among all PCI patients in Massachusetts attributable to secular changes since the onset of public reporting (95% confidence interval: -0.20 to -0.83, p = 0.002).

CONCLUSIONS

The risk profile of PCI patients at outlier institutions was significantly lower after public identification compared with nonoutlier institutions, suggesting that risk-aversive behaviors among PCI operators at outlier institutions may be an unintended consequence of public reporting in Massachusetts.

Angiographic validation of the American College of Cardiology Foundation-the Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies study

BACKGROUND

The goal of this study was to compare angiographic interpretation of coronary arteriograms by sites in community practice versus those made by a centralized angiographic core laboratory.

METHODS AND RESULTS

The study population consisted of 2013 American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) records with 2- and 3- vessel coronary disease from 54 sites in 2004 to 2007. The primary analysis compared Registry (NCDR)-defined 2- and 3-vessel disease versus those from an angiographic core laboratory analysis. Vessel-level kappa coefficients suggested moderate agreement between NCDR and core laboratory analysis, ranging from kappa=0.39 (95% confidence intervals, 0.32-0.45) for the left anterior descending artery to kappa=0.59 (95% confidence intervals, 0.55-0.64) for the right coronary artery. Overall, 6.3% (n=127 out of 2013) of those patients identified with multivessel disease at NCDR sites had had 0- or 1-vessel disease by core laboratory reading. There was no directional bias with regard to overcall, that is, 12.3% of cases read as 3-vessel disease by the sites were read as <3-vessel disease by the core laboratory, and 13.9% of core laboratory 3-vessel cases were read as <3-vessel by the sites. For a subset of patients with left main coronary disease, registry overcall was not linked to increased rates of mortality or myocardial infarction.

CONCLUSIONS

There was only modest agreement between angiographic readings in clinical practice and those from an independent core laboratory. Further study will be needed because the implications for patient management are uncertain.

Hospital variation in survival after in-hospital cardiac arrest

BACKGROUND

In-hospital cardiac arrest (IHCA) is common and often fatal. However, the extent to which hospitals vary in survival outcomes and the degree to which this variation is explained by patient and hospital factors is unknown.

METHODS AND RESULTS

Within Get with the Guidelines-Resuscitation, we identified 135 896 index IHCA events at 468 hospitals. Using hierarchical models, we adjusted for demographics comorbidities and arrest characteristics (eg, initial rhythm, etiology, arrest location) to generate risk-adjusted rates of in-hospital survival. To quantify the extent of hospital-level variation in risk-adjusted rates, we calculated the median odds ratio (OR). Among study hospitals, there was significant variation in unadjusted survival rates. The median unadjusted rate for the bottom decile was 8.3% (range: 0% to 10.7%) and for the top decile was 31.4% (28.6% to 51.7%). After adjusting for 36 predictors of in-hospital survival, there remained substantial variation in rates of in-hospital survival across sites: bottom decile (median rate, 12.4% [0% to 15.6%]) versus top decile (median rate, 22.7% [21.0% to 36.2%]). The median OR for risk-adjusted survival was 1.42 (95% CI: 1.37 to 1.46), which suggests a substantial 42% difference in the odds of survival for patients with similar case-mix at similar hospitals. Further, significant variation persisted within hospital subgroups (eg, bed size, academic).

CONCLUSION

Significant variability in IHCA survival exists across hospitals, and this variation persists despite adjustment for measured patient factors and within hospital subgroups. These findings suggest that other hospital factors may account for the observed site-level variations in IHCA survival.

How does the 'Heart Team' decision get enacted for patients with coronary artery disease?

OBJECTIVES

A heart team approach has been recommended for managing patients with coronary artery disease. Although this seems to be a new concept, we have been developing such a practice for over 8 years. In this report, the enactment of the heart team decision is reviewed and possible improvement is discussed.

DESIGN

Review of 1000 heart team decisions over a 1-year period for patients with coronary artery disease. These decisions were recorded contemporaneously at the time of the team discussion. Thereafter, patient's notes were reviewed 6 months following the heart team meeting to assess whether the decision was enacted and, if not, what were the reasons for aberration.

RESULTS

The heart team decision was enacted in 95.5% of patients. The reasons for aberration in the remaining 45 patients included patient's choice (refusal), unrecognised comorbidities at the time of the heart team discussion, change in patient's clinical condition requiring urgent intervention and death while awaiting procedure, among others.

CONCLUSIONS

The decision of a well set-up heartteam meeting is carried out for most patients. Aberration is uncommon and usually due to unknown factors at the time of the discussion. The heart team approach ensures that patients receive best available care (most likely evidence-based), and demonstrates transparency.

Patient and hospital characteristics associated with inappropriate percutaneous coronary interventions

OBJECTIVES

This study sought to examine whether rates of inappropriate percutaneous coronary intervention (PCI) differ by demographic characteristics and insurance status.

BACKGROUND

Prior studies have found that blacks, women, and those who have public or no health insurance are less likely to undergo PCI. Whether this reflects potential overuse in whites, men, and privately insured patients, in addition to underuse in disadvantaged populations, is unknown.

METHODS

Within the National Cardiovascular Data Registry CathPCI Registry, we identified 221,254 nonacute PCIs performed between July 2009 and March 2011. The appropriateness of PCI was determined using the Appropriate Use Criteria for coronary revascularization. Multivariable hierarchical regression was used to evaluate the association between patient demographics and insurance status and inappropriate PCI, as defined by the Appropriate Use Criteria.

RESULTS

Of 211,254 nonacute PCIs, 25,749 (12.2%) were classified as inappropriate. After multivariable adjustment, men (adjusted odd ratio [OR]: 1.08 [95% CI: 1.05 to 1.11]; p < 0.001) and whites (adjusted OR: 1.09 [95% CI: 1.05 to 1.14]; p < 0.001) were more likely to undergo an inappropriate PCI in comparison with women and nonwhites. Compared with privately insured patients, those who had Medicare (adjusted OR: 0.85 [95% CI: 0.83 to 0.88]), other public insurance (adjusted OR: 0.78 [95% CI: 0.73 to 0.83]), and no insurance (adjusted OR: 0.56 [95% CI: 0.50 to 0.61]) were less likely to undergo an inappropriate PCI (p < 0.001). In addition, compared with urban hospitals, those admitted at rural hospitals were less likely to undergo inappropriate PCI, whereas those at suburban hospitals were more likely.

CONCLUSIONS

For nonacute indications, PCIs categorized as inappropriate were more commonly performed in men, whites, and those who had private insurance. Higher rates of PCI in these patient populations may, in part, be due to procedural overuse.

Analysis Of Medicare Advantage HMOs compared with traditional Medicare shows lower use of many services during 2003-09

Enrollment in Medicare Advantage, the managed care program for Medicare beneficiaries, has grown rapidly, from 4.6 million enrollees in 2003 to 12.8 million by 2012, or 27 percent of all current Medicare beneficiaries. We analyzed utilization patterns of enrollees in Medicare Advantage health maintenance organization (HMO) plans compared to matched samples of people in traditional Medicare during 2003-09, to ascertain whether the HMO enrollees demonstrated different levels of use of services, which can be a hallmark of more integrated care. We found that utilization rates in some major categories, including emergency departments and ambulatory surgery or procedures, generally were 20-30 percent lower in Medicare Advantage HMOs in all years. Medicare Advantage HMO enrollees initially had lower rates of ambulatory visits and hospitalizations, although these rates converged by 2008; they also received about 10 percent fewer hip or knee replacements. In contrast, HMO enrollees underwent more coronary bypass surgery than patients in traditional Medicare. These findings suggest that overall, Medicare Advantage HMO enrollees might use fewer services and be experiencing more appropriate use of services than enrollees in traditional Medicare.