Revascularization In New York State: High Questionable Rates For PCI But Not CABG Reply

A large study looking at real world usage of elective coronary artery bypass surgery (CABG) and stenting (PCI) in New York State finds that nearly two-thirds of PCI procedures have inappropriate or uncertain indications. By contrast, 90% of CABG procedures were deemed appropriate and 1.1% inappropriate.

In a paper published in the Journal of the American College of Cardiology, Edward Hannan and colleagues analyzed data  from NY State patients who received CABG or PCI in 2009 and 2010 and applied appropriate use criteria (AUC) from the ACC, the AHA, and other organizations. (The study only included patients without an acute coronary syndrome (ACS) or previous CABG, as these indications have not generally been the subject of previous concern. By contrast, a large, controversial study last year, that found a significant percentage of nonacute PCIs were performed for inappropriate or uncertain indications, included patients both with and without ACS.)

Here are the main findings of the study:

CABG:

  • Appropriate: 90.0%
  • Inappropriate: 1.1%
  • Uncertain: 8.6%

PCI:

  • Appropriate: 36.1%
  • Inappropriate: 14.3% (91% of these had 1- or 2-vessel disease without proximal LAD disease and little or no anti-ischemic medical therapy)
  • Uncertain: 49.6%

The investigators also found significant variation in utilization among hospitals: “the treatment recommended to patients without ACS was very much dependent on the hospital in which they were treated.” The authors also noted that their study was unable to assess the amount of underuse of revascularizatioin in NY State. They wrote that their “intent is to share these findings with clinicians and to work collaboratively to reduce inappropriate clinical decisions and variations in hospital and cardiologist practice patterns.”

In an accompanying editorial comment, John Spertus and Paul Chan, who were co-authors on the previous JAMA study, acknowledge that “there are certain to be patients rated as inappropriate for which almost all competent cardiologists would recommend intervention.” They recommend that in such cases the physician should “very clearly document the extenuating circumstances that warranted revascularization.” However, the presence of a wide variation among hospitals in the proportion of inappropriate cases suggests that “there is room for improvement in clinical decision-making for coronary revascularization.”

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