A majority of Medicare patients with stable coronary artery disease who underwent an elective percutaneous coronary intervention (PCI; procedure such as angioplasty or stenting to open narrowed coronary arteries) did not have a recommended stress test performed to confirm the necessity of the procedure, according to a study in the October 15 issue of JAMA.
In the United States, PCI has become a common treatment strategy for patients with stable coronary artery disease (CAD), and its use has increased substantially over the past decade. "However, multiple studies have established that some important outcomes for patients with stable CAD (death and risk of future myocardial infarction [heart attack]) do not differ between patients treated with PCI plus optimal medical therapy and patients treated with optimal medical therapy alone," the authors write. Several professional organizations have jointly published guidelines for PCI, which call for documenting ischemia (inadequate blood supply to an area of the heart) in patients with stable coronary artery disease prior to elective PCI. Previous studies have shown that patients who receive PCI in accordance with these guidelines have better outcomes.
Grace A. Lin, M.D., M.A.S., of the University of California, San Francisco, and colleagues conducted a study of Medicare beneficiaries undergoing elective PCI to determine the frequency with which stress testing (which documents ischemia) was performed prior to PCI. The researchers analyzed claims data from a 20 percent random sample of 2004 Medicare fee-for-service beneficiaries age 65 years or older who had an elective PCI (n = 23,887).
The researchers found that of this study group, 44.5 percent (n = 10,629) of patients underwent stress testing within the 90 days prior to elective PCI. There was significant geographic variation in the rate of stress testing by hospital referral region, with rates ranging from a low of 22.1 percent to a high of 70.6 percent. The rate of stress testing did not correlate with the volume of PCI procedures performed in the hospital referral region. Patients who had a prior cardiac catheterization (the passing of a thin flexible tube into the right or left side of the heart to obtain diagnostic information or to provide treatment) were less likely to undergo stress testing prior to elective PCI.
Female sex, age of 85 years or older, and having co-existing illnesses such as rheumatic disease, chronic obstructive pulmonary disease, congestive heart failure, and CAD were associated with decreased likelihood of stress testing prior to PCI. Conversely, patient characteristics associated with an increased likelihood of a stress test prior to PCI were black race and having a history of chest pain. Patients of physicians who performed a higher volume of PCI procedures had slightly lower rates of stress testing. No hospital characteristics were associated with receipt of stress testing.
"Guidelines for PCI call for documenting ischemia prior to PCI in the vast majority of patients with stable CAD; however, our data suggest that this is not being done consistently. Assessing whether PCI is being performed in appropriately selected patients is crucial to providing high-quality, patient-centered medical care in light of evidence that patients in regions providing high-intensity care do not have better (and sometimes have worse) outcomes than those in regions providing low-intensity care," the authors write.
"In addition, because Medicare spends $10,000 to $15,000 per PCI and PCI has accounted for at least 10 percent of the increase in Medicare spending since the mid-1990s, it is important to document that patients are receiving PCI for appropriate indications to ensure the optimal use of Medicare resources. Our findings highlight an opportunity for improvement in the care of patients with stable CAD and suggest that current proposals to restructure Medicare payment to reward hospitals and physicians who adhere to guidelines would improve the safety and delivery of health care to Medicare beneficiaries while decreasing Medicare expenditures on costly and inappropriate procedures."
(JAMA. 2008;300[15]:1765-1773. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: The Disconnect Between Practice Guidelines and Clinical Practice—Stressed Out
In an accompanying editorial, George A. Diamond, M.D., and Sanjay Kaul, M.D., of Cedars-Sinai Medical Center and University of California, Los Angeles, write that properly designed economic incentives might balance competing influences regarding the use of PCI.
"The Centers for Medicare & Medicaid Services, for example, might set reimbursement for evidence-based care at a higher level than for non–evidence-based care. Thus, a cardiologist performing PCI for a patient with objective evidence of ischemia despite an appropriate intensity of medical therapy would be paid more than for the same patient without such evidence. Unlike 'pay-for-performance' these evidence-based reimbursement incentives target individual physician decisions rather than aggregate patient outcomes, are based on empirical data rather than consensus opinion, and are relatively large in size and immediate in effect."
(JAMA. 2008;300[15]:1817-1818. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.
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