Inside Cardiology's PCI Problem

Cheryl Clark, for HealthLeaders Media , August 18, 2011

"If you have to get a flat tire, don't get one in front of that hospital; it's a real heart mill," I used to hear physicians say as they rolled their eyes. "If their cardiologists spot you, you're sure to get cathed."

The doctors were only partly joking. The adage was that interventionalists at that facility set extremely low thresholds to determine if an otherwise healthy, non-emergent passer-by needed angioplasty.

A report in the July 6 issue of the Journal of the American Medical Association gives credence to that "heart mill" phenomenon. Looking at some 144,737 non-acute percutaneous coronary intervention (PCI) procedures for elective patients performed at 1,100 hospitals, the authors deemed only 50% of the procedures appropriate, 12% downright unnecessary and for another 38%, the need was unclear.

And, within that undetermined 38%, a significant number might be categorized as inappropriate if more information had been provided.

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By my calculation, if only one-third of the 38% were truly inappropriate, it would mean 24% of PCIs, roughly one in four, should not have been performed.

The researchers drilled their data down to individual hospitals' catheterization labs. There, they found, "substantial hospital-level variation in the proportion of inappropriate procedures in non-acute settings, ranging from 0% to 55%. Collectively, these findings suggest an important opportunity to examine and improve the selection of patients undergoing PCI in the non-acute setting."

The finding suggests a far greater "likelihood of patients with identical clinical characteristics receiving an inappropriate PCI at one randomly selected hospital as compared with another," wrote the authors, Paul Chan, MD, cardiologist with Saint Luke's Mid America Heart and Vascular Institute in Kansas City and colleagues from 11 other hospital systems.

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1 comments on "Inside Cardiology's PCI Problem"

Will ElLaissi (8/19/2011 at 2:59 PM)
First, I must say that your article is great. It shed insight on the implications of over-stenting and the complications that can arise. Recently, it was reported, I believe in the NEJM, that PCIs could be performed in an out-patient setting due to the competence of invasive cardiologists (meaning that there is now little threat that an artery could burst producing a need for emergency open heart surgery). I work in the industry and I do feel torn by one issue that you raised. You mentioned that some hospitals hang their hat on their cardiology program and the margins that they receive from angioplasties, CABGs, or Valve replacements. We are certainly in this industry to help the patient, but a disconnect appears when we discuss ways to correctly incentivize physicians AND hospitals to cut down on the "inappropriate" PCI cases. It is a hard sell as a consultant or a policy maker to pitch quality when many hospitals suffer for higher quality (Of course we do, but you address the problems that arise). I guess this is the catch in our healthcare system. We are all in healthcare to improve it and to seek options that would improve the way healthcare is delivered to the patient, but practically speaking, we see the downside of doing the right thing. The hope I am sure is that ACOs and bundled payments will help correctly incentivize hospitals and physicians towards higher quality outcomes at lower costs. However, practically speaking, for hospitals that enjoy the lucrative nature of high margin procedures which allow them to stay "in the black" or not deep in the red, can they afford higher quality of care? Will shared savings correctly create the needed incentives? Because as I mentioned, there is no doubt that everyone has picked this industry to create the best care for the patient.




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