Inappropriate vs. rare

That studies still identify inappropriate use of a test or procedure should not be a surprise. They may represent cases that fail to fit neatly into the scenarios described in appropriate use criteria as well as possible overuse.

Recently published analyses of appropriate use criteria highlight some issues.

In 2011, Paul S. Chan, MD, a cardiologist at Saint Luke's Mid America Heart and Vascular Institute in Kansas City, Mo., and colleagues reported that 98.6 percent of PCIs for acute MIs were deemed appropriate, while almost 12 percent of procedures performed on non-acute patients were classified as inappropriate. The analysis was based on PCIs submitted to the American College of Cardiology’s National Cardiovascular Data Registry between 2009 and 2010.

The Chan group recently examined the data on non-acute PCIs from 2009 to 2011, looking at the association between patient and hospital characteristics and potential overuse. In the study, the rate of inappropriate procedures was 12.2 percent.

Registries provide hospitals with a resource to assess their performance, identify opportunities for improvement and initiate changes that increase quality and value. It is possible that the time difference in the two studies was too narrow to capture outcomes from improvements. It also is possible that what was best for a patient appeared to be inappropriate, subtle distinctions that aren’t picked up in registry data. A recent comparison of EHR data and chart reviews cast doubt on the accuracy of EHRs.    

Actual inappropriate use still occurs, at the price of potential harm to patients, increased costs and undermining of benefits from appropriate use. For instance, an evaluation of 1,511 consecutive patients who underwent outpatient SPECT MPI for heart disease found that, based on 2009 appropriate use criteria, 45.5 percent were inappropriate. The authors cautioned that inappropriate use diminishes the value of SPECT MPI.

They pointed out that participating physicians ordered the scans between 2007 and 2010, mostly before guidelines were published and disseminated. Still, inappropriate use rates varied widely for physicians, from 10 percent to 77 percent. The question is, have the imaging guidelines made a dent in inappropriate use? These findings offer a benchmark.

The term appropriate use has itself undergone a makeover, with inappropriate now termed “rarely appropriate.” While the goal may be to whittle down inappropriate use, there should always be a fraction of legitimate tests and procedures that, while rare, are absolutely appropriate.

Candace Stuart

Cardiovascular Business, editor