Before Elective Angioplasty, Most Patients Do Not Undergo Recommended Stress Test

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Main Category: Cardiovascular / Cardiology
Also Included In: Medicare / Medicaid / SCHIP;  Heart Disease
Article Date: 16 Oct 2008 - 0:00 PDT

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Most Medicare patients who display stable coronary artery disease (CAD) and underwent elective percutaneous coronary intervention (PCI) did not undergo the recommended stress test that would confirm the necessity of the procedure, according to an article released on October 15, 2008 in JAMA.

Percutaneous coronary interventions such as angioplasty or stenting, is an often-used treatment for patients presenting with stable coronary artery disease. Despite its increased use over the past ten years, "multiple studies have established that some important outcomes for patients with stable CAD do not differ between patients treated with PCI plus optimal medical therapy and patients treated with optimal medical therapy alone." While many professional organizations have, in their guidelines for PCI in patients with stable coronary artery disease, recommended documentation of inadequate blood flow to the heart, also known as ischemia. Previously, it has been shown that patients who are in accordance with these guideslines when they receive elective PCI have better outcomes than those who do not.

To investigate the prevalence of stress testing before PCI, Grace A. Lin, M.D., M.A.S., of the University of California, San Francisco, and colleagues, examined a 20% random sample (23,887 patients) of Medicare fee-for-service beneficiaries age 65 years or older in 2004 who had an elective PCI procedure.

Within this study group, 44.5% of patients had a stress test performed within the 90 days before the elective procedure. Geographically, the rate of stress testing varied considerably by hospital referral region, as classified by zip code of residence. Regions with the lowest rates had 22.1% of their patients tested, while the most compliant regions had 70.6%. There was no correlation between these rates with the number of PCI procedures performed in that region. Additionally, it was less likely that a paient would undergo the stress testing if they had previously undergone cardiac catheterization, a diagnostic and treatment technique in which a tube is extended into the heart.

Several factors were associated with a decreased rate of stress testing. These included: being female, or 85 years or older; or having other illnesses such as rheumatic disease, chronic obstructive pulmonary disease, congestive heart failure, and CAD. Other factors were associated with an increased rate of stress testing before PCI. these included: being black or having a history of chest pain.

In examining the physicians themselves, the patients of physicians who performed more PCI procedures tended to have lower rates of stress testing. In the analysis, no characteristics of the hospitals were associated with stress testing frequency.

The authors conclude that this prevalence is not high, and that this is not conducive to proper care."Guidelines for PCI call for documenting ischemia prior to PCI in the vast majority of patients with stable CAD; however, our data suggest that this is not being done consistently. Assessing whether PCI is being performed in appropriately selected patients is crucial to providing high-quality, patient-centered medical care in light of evidence that patients in regions providing high-intensity care do not have better (and sometimes have worse) outcomes than those in regions providing low-intensity care," they write.

The authors add that this procedure may therefore be monopolizing valuable resources. "In addition, because Medicare spends $10,000 to $15,000 per PCI and PCI has accounted for at least 10 percent of the increase in Medicare spending since the mid-1990s, it is important to document that patients are receiving PCI for appropriate indications to ensure the optimal use of Medicare resources. Our findings highlight an opportunity for improvement in the care of patients with stable CAD and suggest that current proposals to restructure Medicare payment to reward hospitals and physicians who adhere to guidelines would improve the safety and delivery of health care to Medicare beneficiaries while decreasing Medicare expenditures on costly and inappropriate procedures."

Frequency of Stress Testing to Document Ischemia Prior to Elective Percutaneous Coronary Intervention
Grace A. Lin; R. Adams Dudley; F. L. Lucas; David J. Malenka; Eric Vittinghoff; Rita F. Redberg
JAMA. 2008;300(15):1765-1773.
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Written by Anna Sophia McKenney
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