Even the use of stress testing and imaging is under the spotlight, so that patients don't undergo tests with higher rates of false positives.
"These are the patients who give us opportunities to be better stewards of our healthcare dollar, in terms of doing angioplasty in people who may not necessarily benefit from it," said Brindis. "This is a changing landscape."
Several other factors are at work to measure appropriateness, including recent endorsement of PCI guidelines by the National Quality Forum six years ago. There's active review of standards for cardiovascular disease severity to determine when the narrowing of an artery is significant enough to merit intervention.
Another issue is the increased recognition that PCIs, largely thought of as a benign intervention, are not harm-free. As the authors of the JAMA article wrote, "patients who undergo PCI are exposed to risks of periprocedural complications and longer-term bleeding and stent thrombosis. Moreover, recent trials in stable patients without acute coronary syndromes have shown that PCI, compared with medical therapy, may provide only a modest population average improvement in symptom relief."
The national need to bend the cost curve is of course another reason for the spotlight, and here's where hospitals need to pay close attention.
Angiography and stenting is enormous business, with an estimated 700,000 or so PCIs performed this year at a cost of $12 billion, half of them acute – which were determined at a 99% rate to be necessary.
But if those among the rest that are injudicious are stopped, hospitals may suffer huge financial losses, especially if they weighted their balance sheets with that revenue.
Hospital leaders and interventional departments should realize that the days of the heart mill will soon be over, if they aren't already, and they should examine any operators whose volume may be in question.
Even though the findings from the NCDR Cath PCI Registry, down to the hospital level, won't be released to the public, presumably peer pressure, as well as increasing accusations against publicly named cardiologists, should be persuasive enough to do the right thing.