JAMA study: Rate of inappropriate stenting is declining

An analysis of registry data shows that medical community efforts to reduce the number of inappropriate stenting procedures have worked. Between 2010 and 2014, the rate of inappropriate nonacute percutaneous coronary interventions (PCIs) to implant stents has fallen from 26.2% to 13.3%, according to a paper in the Journal of the American Medical Association (JAMA) presented at the annual meeting of the American Heart Association.

Efforts to reduce stenting include the publication of appropriate use criteria for coronary revascularization among coronary artery disease patients in 2009 by the American College of Cardiology and American Heart Association, the paper says. In addition, some insurers declined reimbursement deemed inappropriate with the help of a registry on PCI procedures launched in 2011.

The JAMA paper analyzed the registry, dubbed NCDR CathPCI. At the 766 hospitals that participate in the registry, the number of acute PCIs declined by a small amount, from 377,540 in 2010 to 374,543 in 2014, but the number of nonacute procedures fell from 89,704 in 2010 to 59,375 in 2014.

Stents are always appropriate in acute situations, such as after a heart attack, but implantation in nonacute situations (accounting for about 15% of all implantations in 2014) is not always necessary. The number of inappropriate nonacute procedures fell to 7,921 in 2014, from 21,781 in 2010, cutting the rate of unnecessary procedures in half.

Mayo Clinic cardiologist Dr. Raymond Gibbons warned that results may overstate the change because of "upcoding," or the exaggeration of symptoms to make a procedure more likely to be classified as appropriate. That's because subjective rates of the seriousness of those patients' condition (like the percentage who had a high-level of angina) rose more sharply than the percentage of nonacute patients with more than one diseased vessel, which is an objective indicator of severity.

Still, he told The Wall Street Journal that "the absolute decline in the nonacute PCI numbers is striking," and represents an improvement in the quality of care being delivered.

Dr. Ralph Brindis, former president of the American College of Cardiology, told the WSJ that the study data indicating an increase in use of fractional flow reserve technology for patient selection was encouraging. Adoption of the technology increased from 8.1% of nonacute cases in 2010 to 30.8% in 2014.

Also noteworthy was the increase in the percentage of nonacute patients taking at least two anticoagulant medications. The rate rose from 19.3% to 35.1%.

- read the study
- here's more from the Wall Street Journal

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