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Published on: March 15, 2022
Appropriateness of diagnostic catheterization for suspected coronary artery disease in New York State
Edward L Hannan1, Zaza Samadashvili, Kimberly Cozzens
1From the University at Albany, State University of New York (E.L.H., Z.S., K.C.); Johns Hopkins University, Baltimore, MD (G.W.); Mayo Clinic, Rochester, MN (D.R.H.); Boston Medical Center, MA (A.K.J.); United Health Services, Binghamton, NY (N.J.S.); Albany Medical Center, NY (F.J.V.); Mt. Sinai Medical Center, New York, NY (S.S.); and St. Joseph's Health System, Atlanta, GA (S.B.K.).
Insights
Nearly a quarter of diagnostic catheterizations (DC) for suspected coronary artery disease were inappropriate. Many inappropriate procedures involved patients without prior stress tests and low-risk scores, highlighting areas for improved appropriate use criteria adherence.
Area of Science:
- Cardiology
- Health Services Research
Background:
- Recent publication of appropriate use criteria (AUC) for diagnostic catheterization (DC).
- Need to evaluate AUC adherence in a large patient cohort.
Purpose of the Study:
- To assess the appropriateness of DC procedures in a real-world setting using AUC.
- To identify patient and hospital factors associated with inappropriate DC.
Main Methods:
- Analysis of the New York State Cardiac Diagnostic Catheterization Database (2010-2011).
- Categorization of DC procedures as appropriate, uncertain, or inappropriate based on AUC.
- Examination of patient characteristics and hospital-level variables related to appropriateness.
Main Results:
- 35.3% of 8986 patients were appropriate, 39.8% uncertain, and 24.9% inappropriate for DC.
- Among inappropriate cases, 56.7% were asymptomatic with no prior stress test and low/intermediate risk.
- Median hospital inappropriateness rate was 28.5%; not associated with hospital volume or PCI inappropriateness.
Conclusions:
- A significant proportion (24.9%) of diagnostic catheterizations for suspected coronary artery disease did not meet AUC.
- A majority of inappropriate procedures involved patients without prior stress testing and low-risk profiles.
- Findings suggest opportunities to refine AUC implementation and improve procedural appropriateness.
Background:
Appropriate use criteria for diagnostic catheterization (DC) were recently published. These criteria are yet to be examined for a large population of patients undergoing DC.
Methods And Results:
New York State's Cardiac Diagnostic Catheterization Database was used to identify patients undergoing DC for coronary artery disease between 2010 and 2011 for suspected coronary artery disease. Patients were rated by the appropriate use criteria as appropriate, uncertain, and inappropriate for DC. The relationships between various patient characteristics and the appropriateness ratings were examined, along with the relationships between hospital-level inappropriateness, for DC and 2 other hospital-level variables (hospital DC volume and percutaneous coronary intervention inappropriateness). 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/had low or intermediate global coronary artery disease risk, 36.0% had a previous stress test with low-risk findings and no symptoms, and 7.3% were symptomatic/had no previous stress test/had low pretest probability. The median hospital-level inappropriateness rate was 28.5%, with a maximum of 48.8% and a minimum of 8.6%. Hospital-level inappropriateness was not related to hospital volume or inappropriateness for percutaneous coronary intervention.
Conclusions:
One quarter of patients undergoing DC for suspected coronary artery disease were rated as inappropriate for the procedure, approximately two thirds of these inappropriate patients had no previous stress test, and ≈90% of inappropriate patients with no previous stress test were asymptomatic with low or intermediate global risk scores.
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