Regional Variations in PCI Use Declined Post-COURAGE

January 06, 2014

ATLANTA, GA — Following the publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, the geographic differences in the utilization of PCI for the treatment of stable ischemic heart disease declined, according to the results of a new analysis[1].

After COURAGE was published, the overall volume of PCI performed for stable coronary disease declined by 25%, and regional variation also declined by 25%, report investigators.

"Our study joins a couple of others in finding a decrease in the utilization of PCI for stable ischemic heart disease," lead investigator Dr Arun Mohan (Emory University School of Medicine, Atlanta, GA) told heartwire . "Our study is the first, though, to look at what happened to geographic variation, and what we found there was a 25% reduction. That coincides pretty nicely with the reduction in use. We also found there was very little change in the use of PCI for acute coronary syndrome, where we know there is definitive benefit to PCI."

It's been nearly seven years since the COURAGE trial was presented at the American College of Cardiology (ACC) Scientific Sessions in New Orleans, LA and published in the New England Journal of Medicine. The trial was a large comparative-effectiveness study that showed PCI and optimal medical therapy were no better at preventing future events than optimal medical therapy alone in patients with stable coronary disease.

"What is interesting about this opportunity is that the government spends a lot of money in comparative-effectiveness research," Mohan told heartwire . "A big part of the rationale for these trials is that there might be geographic variation in care or doctors don't know what the best course of treatment might be. We invest a lot of money in figuring out what the right response is or what the right treatment for various conditions might be. What's surprising is that nobody has actually gone back and looked at how doctors respond to the research and how that affects geographic variation."

In the study, published online December 17, 2013 in Circulation: Cardiovascular Outcomes and Quality, the researchers analyzed data from 67 hospital referral regions (HRRs) using data from various state databases and compared the age- and sex-adjusted rates of PCI for stable ischemic heart disease before 2006 and after 2008. In total, more than 270 000 PCIs for stable coronary disease were performed in 526 hospitals.

After COURAGE, the volume of PCIs for stable coronary disease declined 25%. The largest reductions in PCI volume were observed in HRRs that performed the most PCIs prior to COURAGE. For example, HRRs in the highest tertile had a 35% reduction in PCI for stable ischemic heart disease after COURAGE, whereas those in the lowest tertile had an 18% reduction.

When the researchers addressed the geographic variations in PCI volume by HRR, they observed a 25% reduction in regional variance. Even though the gap in treatment for ischemic heart disease is closing between regions, investigators say variations in treatment still exist. For example, compared with the treatment of acute coronary syndrome, geographic variation for stable coronary disease is twice as large.

To heartwire , Mohan said the reason for the existing geographic variation is likely attributable to some of the lingering debate on the optimal treatment strategy for stable disease. Even though the COURAGE results were positive and clear, critics of the trial pointed to the fact that patients with high-risk features, such as significant left-main disease and severe left ventricular dysfunction, were excluded from the trial. These, among other criticisms, have led to questions about the generalizability of the COURAGE results in the real world.

"I think there is still some uncertainty around this," said Mohan. "But I think one of the reasons that we're seeing any decrease in variation is that the COURAGE trial was very well regarded and the findings were highly publicized by the ACC and AHA. So all of these things point to the fact that comparative-effectiveness research can have an impact on clinical practice."

The authors report no conflicts of interest.

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