Reflecting a concern about the overuse of percutaneous coronary interventions (PCIs), the 2009 Appropriate Use Criteria (AUC) for coronary revascularization aimed to cut the number of procedures performed in non-acute settings. Despite this, new research published in JACC: Cardiovascular Interventions shows substantial variation between states for non-acute coronary angiograms, PCIs and coronary artery bypass graft (CABG) surgeries.
Senior author Robert W. Yeh, MD, MSc, and colleagues identified nearly 1.2 million coronary angiograms, more than 260,000 non-acute PCIs and almost 100,000 non-acute CABGs taking place in Maryland, New York, Florida and Michigan from 2010 to 2014. The researchers said they chose these states because Maryland’s all-payer system is unique and allows for comparison to that model, and all four states had both inpatient and outpatient data available.
After standardizing the populations to Florida’s 2014 census to eliminate age and sex differences, the researchers noted the following trends:
- All procedures declined in each state from 2010 to 2014, with the exception of coronary angiograms increasing marginally in New York.
- In 2014, Maryland had the lowest rates among the states for all three procedures. The differences were especially stark for angiograms (40 percent fewer than Florida) and PCIs (62 percent fewer than New York).
“It is possible that the heterogeneity we observed reflects the differential uptake of AUC of coronary angiography and PCI, with continued overuse in certain areas of the United States that have lower adoption,” Yeh and coauthors wrote. “It is also possible that the low rates of procedure use in Maryland reflect underuse due to the influence of its unique all-payer system, which is designed to promote cost efficiency. Future investigations should seek to understand the extent to which observed variations among states may, in part, be explained by differences in patient case-mix, academic versus private institution penetrance in each state, or variations in state policies (i.e., public reporting, malpractice, payment models).”
The researchers defined non-acute procedures as any occurring in the absence of unstable angina or myocardial infarction. They noted their work is particularly timely given the vigorous debate over the ORBITA trial published in November, which showed no improvement in exercise duration for patients with stable chest pain who received PCI versus medical therapy alone.
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.