Comment: ACC Circling the Wagons, Once Again Reply

Once again the ACC is circling the wagons. In response to a paper in JAMA finding that about half of all nonacute PCI procedures may be inappropriate, the ACC released a statement assuring everyone that there’s nothing to be concerned about and that all the experts and officials are hard at work mending whatever slight problems may exist. Don’t worry, be happy is the message they want to convey.

Let’s be clear here. The JAMA/NCDR study is no cause for panic, and there’s a very important and reassuring nugget of information at the core of the report (ie, that the overhwelming majority (98.6%) of  PCIs for acute indications are appropriately done). But, on the other hand, the study also raises the possibility that as many as half of all nonacute PCI procedures may be performed with no clear evidence base or expert recommendation. This should not really surprise anyone who’s been paying attention. One prominent cardiologist told me that he was indeed “shocked” by the finding, but only because the study found “that only half of the elective procedures were deemed inappropriate.”

But the ACC statement tries to weasel its way out of this conclusion, summarizing the finding in this yawn-inducing manner:

…this study is timely and suggests that although the majority of patients are appropriately selected for PCI procedures, there is significant variance in therapeutic strategies particularly in the non-emergency setting.

The real point of this statement is to lull us to sleep, to try to convince us not to look behind the curtain, not to question some potentially troubling practice patterns in a substantial portion of US hospitals.

Now the ACC statement includes some very appropriate cautions about the study. Almost certainly, not all the procedures deemed inappropriate by the study are really inappropriate. The authors themselves admit this point in their discussion. And the appropriate use critiera (AUC) used in the study should not be considered absolute or unyielding. But a key point of the JAMA paper (and hidden in the soporific haze of the ACC quote above), demonstrating that there really is something rotten in the state of PCI, is the very wide variability between hospitals in the rate of inappropriate procedures. So we may not know exactly how many inappropriate PCIs are being performed, but the underlying situation is troubling and indefensible.

But the ACC message is that we live in the best of all possible worlds:

“The AUC used in conjunction with the registry has the ability to point out outliers, and can determine opportunities for individual hospitals to monitor their performance and adopt or develop quality improvement initiatives to optimize the care they deliver.

“Studies like these that allow us to see where there are opportunities for improvement are beneficial to patients and to the entire field of medicine. With the benchmarking evidence provided by the Registries, we will continue to see improvements in quality that lead to better care for public and individual health.”

Again, once you get beyond the bureaucratic and obfuscatory language, the message is that there’s nothing actually wrong with things now, but isn’t it wonderful that we can use  studies like this to find “opportunities for improvement.”

So this is yet another example in which the ACC takes the role of a cardiologists’ union or a public relations agency for cardiovascular medicine, as opposed to the role suggested by the word “college” in its name. To be fair, the ACC is right to do what it can to prevent panic. On the other hand, the final outcome of this paper shouldn’t be business as usual.

Here is the ACC statement:

Please note: The American College of Cardiology’s (ACC) NCDR® (National Cardiovascular Data Registry) was the data resource for the upcoming Journal of the American Medical Association article titled, “Appropriateness of Percutaneous Coronary Intervention.” The ACC’s NCDR is the largest, most comprehensive, outcomes-based cardiovascular patient data repository for quality improvement in the United States.

“The study published today in the Journal of the American Medical Association titled “Appropriateness of Percutaneous Coronary Intervention,” is an evaluation of the appropriateness of stent usage in the US. Using data from the NCDR’s CathPCI Registry®, the largest percutaneous coronary intervention (PCI) registry in the US, this study is timely and suggests that although the majority of patients are appropriately selected for PCI procedures, there is significant variance in therapeutic strategies particularly in the non-emergency setting.

“The Appropriate Use Criteria (AUC) for Coronary Revascularization were developed in 2009 by the ACC in conjunction with several other professional societies using a combination of clinical science, knowledge and expert opinion. The results of this study should be interpreted knowing that the AUC are suggested approaches to care. The AUC criteria are not mandated but represent the knowledge and experience base present at the time when the criteria are written. The most important appropriate use approach is full communication of potential risks and benefits of a specific procedure to the patient and family.  Clinical judgment and full patient understanding should always guide care. There may be times when what is best for the individual patient is at variance with either AUC or guidance documents.

“The AUC used in conjunction with the registry has the ability to point out outliers, and can determine opportunities for individual hospitals to monitor their performance and adopt or develop quality improvement initiatives to optimize the care they deliver.

“Studies like these that allow us to see where there are opportunities for improvement are beneficial to patients and to the entire field of medicine. With the benchmarking evidence provided by the Registries, we will continue to see improvements in quality that lead to better care for public and individual health.”

For more information about the NCDR visit http://www.ncdr.com.  For more information about the AUC for Coronary Revascularization, visit http://www.CardioSource.org/AppropriateUse.

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