Both Overuse And Underuse Explain Disparities In Heart Procedures Reply

A new study finds that groups who have often been found to receive less medical care– non-whites, women, and people without private insurance or who are from urban and rural areas– are less likely to undergo coronary revascularization. But the same study finds that this disparity may be in no small part due to the fact that these same groups are less likely to receive inappropriate procedures. The study, published online in the  Journal of the American College of Cardiologysuggests, therefore, that the apparent underuse of healthcare in some groups may be partly counterbalanced by overuse in other groups.

In an interview with CardioExchange, Chan said that although “we have come a long way in ensuring that care is delivered equitably and thoughtfully in the US… there is no doubt that underuse in certain populations remains a persistent and huge problem. For policymakers… it highlights the importance of thinking about differences in treatment in a more complex way– as due to underuse and also potential overuse. Therefore, the goal may be to narrow the gap in vulnerable populations in instances where treatment has clearly established benefit rather than assuming that the measured difference is entirely due to a disparity in care.” Chan also said the paper was consistent with the hypothesis that patients for whom physicians are paid more are more likely to undergo inappropriate procedures.

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Prominent Interventionalists Attack Appropriate Use Criteria For PCI 5

A group of leading interventional cardiologists has launched an attack on the growing role of appropriate use criteria (AUC) for PCI in the US. They argue that severe flaws in current guidelines render unreliable current attempts to assess the rate of appropriate procedures.

In a paper published in  JACC: Cardiovascular Interventions, Steven Marso and colleagues (Paul Teirstein, Dean Kereiakes, Jeffrey Moses, John Lasala, and J Aaron Grantham) criticize a study in JAMA published last year from the National Cardiovascular Data Registry (NCDR) that found a large degree of inappropriate or uncertain PCI procedures, as well as a wide range of variability among institutions. Marso et al write that the JAMA paper sensationalized the data by focusing attention on the low rate of appropriate indications for nonacute PCI– 50.4%– while failing to point out that the study found that 84.6% of procedures in the entire study population– acute and nonacute alike– were deemed appropriate. Furthermore, given the imprecision built into the system, they ask: what is the “acceptable threshold” of inappropriate PCI?

The authors write that the AUC panel “purposefully limited involvement of the interventional community during the development process, in order to avoid having a majority of committee members “whose livelihood is tied to the technology under study.” But the under-representation of interventionists may have biased the results, they argue. One particular case as graded by the AUC panel was the most common reason for cases to be categorized as inappropriate: the AUC committee decided that PCI was inappropriate for a patient with 1- to 2-vessel disease, no proximal LAD involvement or prior CABG, class I or II symptoms, low-risk noninvasive findings, and on no or minimal medications. But most clinicians believe this is an uncertain but not inappropriate indication, they say.  The AUC panel may have “got this one wrong,” they write.
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