{"id":16131,"date":"2012-02-21T00:24:33","date_gmt":"2012-02-21T05:24:33","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=expert-is-in&p=16131"},"modified":"2012-02-21T00:24:36","modified_gmt":"2012-02-21T05:24:36","slug":"part-4-clashing-views-of-appropriate-use-criteria-for-pci","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2012\/02\/21\/part-4-clashing-views-of-appropriate-use-criteria-for-pci\/","title":{"rendered":"Part 4: Clashing Views of Appropriate Use Criteria for PCI"},"content":{"rendered":"

In\u00a0a recent Viewpoint in JACC: Cardiovascular Interventions<\/a>,\u00a0Marso\u00a0and colleagues\u00a0expressed grave reservations about the application of appropriate use criteria for PCI in a\u00a0controversial study published last year in JAMA<\/a>\u00a0by Chan\u00a0and colleagues,\u00a0which found that only half of PCIs performed for nonacute indications were classified as appropriate. Interventional cardiology editors\u00a0Rick Lange and David Hillis asked CardioExchange members for their opinions<\/a>\u00a0on this topic. In this series of posts, Lange and Hillis question the main protagonists in the debate,\u00a0Steven Marso<\/strong>\u00a0and\u00a0Aaron Grantham<\/strong>, on the one side, and\u00a0Paul Chan<\/strong>\u00a0and\u00a0John Spertus<\/strong>\u00a0on the other side. All the authors are affiliated with the\u00a0Saint Luke’s Mid America Heart Institute in Kansas City, Missouri.\u00a0<\/em>Click\u00a0for\u00a0Part 1<\/a>,\u00a0Part 2<\/a>, and Part 3<\/a>\u00a0of this debate.<\/em><\/p>\n

Lange & Hillis:\u00a0<\/strong>According to the study by Chan et al, only 50% of PCIs performed for non-acute indications were deemed to be appropriate; 38% were said to be \u201cuncertain\u201d and 12% inappropriate. In your opinion, is this a reflection of (a) obsolete AUC criteria, (b) unreliable data for determining appropriateness, or (c) PCI procedures being performed unnecessarily? Would the results be different if the 2012 updated AUC were utilized?<\/strong><\/p>\n

Chan & Spertus:\u00a0<\/strong>We believe that these are the best data available and that the publication is leading to substantial reflection about the indications for PCI. This is a very healthy process, as emphasized by the recent perspective of Marso and colleagues. It is prompting numerous innovative strategies among hospitals around the country to improve care, including a) deferring PCI in some cases that are inappropriate; b) supporting \u2018cath conferences\u2019 that discuss the indications for treatment, rather than just rates of procedural success or failure; c) encouraging the prospective assessment of appropriateness and implementing \u2018mandatory second opinions\u2019 in the cath lab prior to conducting procedures deemed inappropriate; and d) improving documentation and the quality of data abstraction. We believe that the 2012 update will further improve the accuracy of mapping patients and will reflect the latest available clinical data. Improvements in rates of PCI appropriateness are likely to reflect all of theses changes, including improved documentation, data abstraction and patient selection.<\/p>\n

Marso & Grantham:<\/strong>\u00a0In the Chan paper, the overall inappropriate rate for all PCIs was 4.2%. You are referencing the \u201cI\u201d rate for the non-acute PCI indications.\u00a0The inappropriate rate of 12% in the non-acute indications may a function of all of the things you mention. However, it is likely that obsolete criteria do not play a deterministic role in the inappropriate rate.<\/p>\n

We believe the data for stress testing and likely CCS is unreliable in the NCDR. The inappropriate rate is also a function of clinicians seeing relative value for CCS 2 and\/or 12B when the AUC technical panel does not. Recall there was broad disagreement between the AUC technical panel and clinicians when assessing the appropriateness of this category. Certainly the \u201cI\u201d rate is also a function of inappropriate PCI being performed. We just cannot be certain whether this is a significant or minor fraction of the reported I rate of 12%.<\/p>\n

 <\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

In\u00a0a recent Viewpoint in JACC: Cardiovascular Interventions,\u00a0Marso\u00a0and colleagues\u00a0expressed grave reservations about the application of appropriate use criteria for PCI in a\u00a0controversial study published last year in JAMA\u00a0by Chan\u00a0and colleagues,\u00a0which found that only half of PCIs performed for nonacute indications were classified as appropriate. Interventional cardiology editors\u00a0Rick Lange and David Hillis asked CardioExchange members for their […]<\/p>\n","protected":false},"author":229,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1,9],"tags":[1147,301],"class_list":["post-16131","post","type-post","status-publish","format-standard","hentry","category-general","category-interventional-cardiology","tag-appropriate-use-critiera","tag-pci"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/16131","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/229"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=16131"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/16131\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=16131"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=16131"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=16131"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}