Inside Cardiology's PCI Problem

Cheryl Clark, 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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