Medical panel lists ways to reduce PCI overuse

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Elective PCI is one of five procedures or treatments that are problematically overused, according to a joint panel of medical experts. They highlighted strategies to reduce PCI overuse and offered four proposed interventions.

“While many medical procedures are associated with tradeoffs between benefits and risks, the risks that are incurred in instances of overuse are not balanced by benefits to patients,” wrote panelists representing the American Medical Association-Convened Physician Consortium for Performance Improvement (AMA-PCPI) and The Joint Commission.

The National Cardiovascular Data Registry (NCDR) reported that 6 percent of elective PCI procedures did not meet the American College of Cardiology’s (ACC) Appropriate Use Criteria in 2012, a decrease from 12 percent in 2011. The Accreditation for Cardiovascular Excellence estimated that 8 percent of PCI procedures are inappropriate.

In February, the ACC changed terminology for the categories to “Appropriate Care,” “May Be Appropriate Care” and “Rarely Appropriate Care” to reflect nuances in clinical judgment. Care that falls under the “Rarely Appropriate” category typically lacks a clear benefit-risk advantage or is rarely an effective option. 

In its report, the group addressing elective PCI focused on the use of the procedure in patients with stable ischemic heart disease. The authors pointed to strategies already in place to reduce overuse, including participation in the NCDR or other databases; additional accreditation or certification; the Society for Cardiovascular Angiography Quality Improve Toolkit; and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium PCI Quality Improvement Initiative.

They also listed four proposed interventions.

The first, standardized reporting in the catheterization and interventional report,  includes developing a standardized template based on the criteria; using an additional “’time-out’” during the procedure to ensure proper documentation related to the elective PCI indications; and a formal periodic case review and a database for random case review.

The second is standardized analysis and interpretation of noninvasive testing for ischemia. There should be standardized reporting that addresses radiation safety, appropriate use and the extent and severity of ischemia. They also suggest criteria for stress testing that includes referral and interpretation guidelines.

A third proposal is to emphasize informed consent and patient education about the risks and benefits of the procedure. “If the indications for PCI are found to be uncertain or inappropriate by the heart team, criteria and/or guidelines, the rationale for the team’s recommendation and a follow-up plan would be provided in a way that the patient can read and attest to understanding,” the panel suggested.

The fourth intervention stressed the importance of raising awareness among patients and health professionals about appropriate treatment.

Besides elective PCI, the panel targeted antibiotic treatment for viral upper respiratory infections, tympanostomy tubes for short-duration middle ear effusion, early-term nonmedically indicated elective delivery and over-transfusion of red blood cells as “areas that have triggered concerns about overuse and quality.”

The report released July 10 was based on a meeting of the National Summit on Overuse. Overuse, the panel stressed, can be medically harmful to patients and is economically harmful to the general public. One summit speaker, PCPI chair Bernard Rosof, MD, said unnecessary medical care costs the U.S. about $210 billion annually.

“As part of our strategic focus on improving health outcomes, one of our goals is to contribute to the appropriate use of finite healthcare resources and this will help us achieve our goal,” said AMA president Ardis D. Hoven, MD, in a press release.