In the JournalsPerspective

Demographic disparities exist in rates of inappropriate PCI

Men and white patients carried an increased risk for receiving inappropriate PCI compared with other patient groups, findings published in the Journal of American College of Cardiology suggest.

Because previous research has indicated that blacks, women and those with public or no health insurance are less likely to receive PCI, Paul S. Chan, MD, MSc, with Saint Luke’s Mid America Heart Institute in Kansas City, Mo., and colleagues aimed to investigate whether patient demographics or insurance status affect rates of inappropriate intervention. The analysis included 221,254 non-acute PCIs culled from the CathPCI Registry. Eligibility dates were July 2009 to March 2011 and eligibility criteria were defined by the appropriate use criteria (AUC) for coronary revascularization.

The rate of inappropriate PCI among 211,254 non-acute procedures was 12.2%.


Paul S. Chan

Multivariate analysis results indicated that men (adjusted OR=1.08; 95% CI, 1.05-1.11) and whites (adjusted OR=1.09; 95% CI, 1.05-1.14) were at an increased risk for inappropriate PCI compared with women and non-whites.

Less frequent inappropriate PCI was performed in patients with Medicare (adjusted OR=0.85; 95% CI, 0.83-0.88), other public insurance (adjusted OR=0.78; 95% CI, 0.73-0.83) and no insurance (adjusted OR=0.56; 95% CI, 0.50-0.61) than in patients with privately held insurance (P<.001).

Higher rates of inappropriate PCI were observed in urban hospitals compared with patients admitted to rural hospitals. Suburban hospitals yielded the highest inappropriate PCI rates.

“Higher rates of PCI in these patient populations may be, in part, due to procedural overuse,” Chan and colleagues concluded.

Overuse as bad as underuse?

In an accompanying editorial, Karen E. Joynt, MD, MPH, of the division of cardiovascular medicine and the department of internal medicine at Brigham and Women’s Hospital, raised the question of whether overuse is as bad as underuse.

“This is actually a somewhat difficult question to answer,” Joynt wrote. “The economic consequences are straightforward — needless spending for no clinical benefit. The clinical consequences of overuse of PCI, however, are more complex.”

Karen Joynt 

Karen E. Joynt

Joynt said unnecessary procedures are associated with increased risks for bleeding, stroke and MI, among other adverse events.

“However, given that, in general, the patients on whom procedures are overused are a healthier group undergoing elective procedures, their outcomes are still good,” she wrote, citing previous research indicating that inappropriate PCI is not necessarily associated with unfavorable clinical outcomes. “The clinical consequences of overuse thus remain largely invisible, at least on a population level.”

Study limitations, contributions

Regarding the study findings, Joynt said the analysis lacks a broader denominator.

“We are missing the non-PCI patients from the [National Cardiovascular Data Registry] database, and therefore it is difficult to know what the ‘right’ rates of PCI in these populations really are,” she wrote. “It is quite feasible — and, given the wealth of data suggesting that PCI is underused in women and black patients, even likely — that there is concurrent underuse and overuse, and that the optimal use of this important procedure lies somewhere in between.”

In a statement issued by the American College of Cardiology, Ralph Brindis, MD, MACC, past-president of ACC, said that it is important to keep in mind that the AUC terminology has been updated since the creation of the present study. One change, he noted, is that the term “inappropriate” is now “rarely appropriate.”


Ralph Brindis

“The new terminology acknowledges that in certain rare cases when the patient’s individual circumstances are considered as part of a shared decision-making process, stents in this category would be considered ‘appropriate,’” Brindis said in the statement. “At present, we are better equipped to measure ‘rarely appropriate’ or overuse of care than determining the underuse of care.”

Despite the study limitations, Joynt said the findings should contribute to the body of evidence on the subject.

“These findings are important because they make clear the types of interventions that are most (and least) likely to be effective in improving the overall quality of care delivered for CVD,” she wrote. “Programs aimed at simply increasing the appropriate use of cardiac procedures such as cardiac catheterization and PCI will not, in and of themselves, do enough to improve quality — and in fact, they may widen disparities by increasing use in white patients and men even further.”

She said programs designed solely to decrease inappropriate PCI may not be effective. “Both sides of the quality paradigm — underuse and overuse — must be together at the forefront of our quality improvement efforts.”

For more information:

Chan PS. J Am CollCardiol. 2013; [published online ahead of print Sept. 18].

Joynt KE. J Am CollCardiol. 2013; [published online ahead of print Sept. 18].

Disclosure: See the study for a full list of researchers’ disclosures. Brindis reports serving on the speakers’ bureau of Volcano and receiving consultant fees/honoraria from Ivivi Health Sciences. Joynt reports no relevant financial disclosures.


Theodore A. Bass

  • The AUC are a process. What they deal with are evidence and experience. They are evolutionary. They will continually evolve as new evidence comes out and as techniques and technologies change. This study by Chan and colleagues started collecting information from 2009 when the AUC were first published and followed patients for about 2 years. It is important to note that it takes a while for the recommendations of the AUC to infiltrate practice.

    Although I’m not saying that possible overuse shouldn’t be addressed just as underutilization should be examined when looking at healthcare disparities, I’m not sure what to do with the data at this point. Should our target of practice be appropriate use or work to achieve the best patient-centered outcomes? It clearly has to be patient outcomes. We have no data in this dataset telling us how our patients are doing and no data on quality of life.

    Ultimately, health care disparities are very important and we have to address them, and that’s my take-home message from this study: it puts the disparities on the table for us to talk about. Appropriate use offers a tool for practitioners. It’s not necessarily an endpoint in itself and I don't think the first attempt regarding this model was ready to be tested in this way. In the past 7 years, PCI utilization (most notably in elective situations) has decreased. The emergence of new data, the increased use of clinically predictive diagnostic tools such as fractional flow reserve to dictate physiological need for intervening has helped our decision-making process regarding which patients best benefit from elective PCI, the patient population addressed in this study. As a result, I feel the message of this paper is dated. It would be interesting to see what more current data from the last 2 years show us.

    • Theodore A. Bass, MD
    • Professor of Medicine, University of Florida, Jacksonville
      President, Society for Cardiovascular Angiography and Interventions
  • Disclosures: Bass reports no relevant financial disclosures.