One in Four Diagnostic Catheterizations Inappropriate: NY Study

Marlene Busko

January 31, 2014

RENSSELAER, NY — One in four patients who underwent recent diagnostic catheterizations in 18 New York state hospitals to detect suspected CAD were not appropriate candidates for this procedure, based on new criteria[1], a study reports[2].

Among the patients who had undergone inappropriate diagnostic catheterization, 57% had no chest pain, no previous stress test, and a low to intermediate Framingham global CAD risk score.

"It appears that there are a lot of patients who are getting this procedure who don't really need it, and [physicians] need to look over the appropriateness criteria carefully before making a decision as to whether or not to use" diagnostic catheterization, Dr Edward L Hannan (State University of New York, University at Albany, Rensselaer, NY) told heartwire .

"The implications . . . are that it is an expensive procedure, and it sometimes can lead to complications [or] adverse outcomes; so . . . you shouldn't be doing it when it doesn't need to be done."

The criteria were published after the time frame of the study, Hannan acknowledged. Nevertheless, they identified wide variations in the rate of inappropriate procedures in different hospitals—ranging from 9% to 49%. This "huge variation . . . would suggest that there should be ways to get some hospitals to bring their rates down to what other hospitals are able to accomplish, regardless of what the [study] caveats are."

The study was published online January 28, 2014 in Circulation: Cardiovascular Interventions.

When Is a Coronary Angiogram Necessary?

Recent studies have pointed to a need for a more cost-effective use of the cardiac catheterization laboratory, the researchers write. The new appropriateness criteria provided a timely measure to see whether hospitals were sending the right patients to the cath lab for diagnostic catheterization for suspected CAD.

"The American College of Cardiology, the American Heart Association, and a few other societies convened a group to help them determine whether or not a patient should have diagnostic catheterization," Hannan explained. Using methodology developed by the RAND Corporation (Santa Monica, California), the group of experts determined criteria to classify diagnostic catheterization as appropriate, inappropriate, or uncertain (meaning that based on current evidence the procedure could be either appropriate or inappropriate).

Hannan and colleagues aimed to use data from New York State's Cardiac Diagnostic Catheterization database to identify patients undergoing this procedure between 2010 and 2011 for suspected CAD and to determine the appropriateness of the procedure.

They examined data from 18 hospitals out of about 80 hospitals in the state where diagnostic catheterization is available.

Of the 8986 patients who could be rated for appropriateness, 35.3% were rated as appropriate, 39.8% as uncertain, and 24.9% as inappropriate.

Of the 2240 patients rated as inappropriate:

  • 56.7% were asymptomatic, had no previous stress test, and had low or intermediate global coronary artery disease risk.

  • 36.0% had a previous stress test with low-risk findings and no symptoms.

  • 7.3% were symptomatic, had no previous stress test, and had low pretest probability.

"It is notable that . . . 64% of all patients with suspected CAD who were rated as inappropriate" for diagnostic catheterization had no prior stress test, the authors write, adding that "the vast majority of these patients (89%) were asymptomatic with low or intermediate global CAD risk scores."

Hospital-level inappropriateness was not related to the number of patients who underwent the procedure or to inappropriateness for PCI.

Hannan had no conflicts of interest. Disclosures for the coauthors are listed in the paper.

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