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Combined cardiac catheterization for uncomplicated ischemic heart disease in a Medicare population
C Laine1, L Venditti, R Localio
1Keystone Peer Review Organization, Harrisburg, Pennsylvania, USA.
Insights
Combined cardiac catheterization rates for uncomplicated heart disease vary widely. The common reason, planned revascularization, lacks specific indication, suggesting practice variation not evidence-based.
Area of Science:
- Cardiology
- Health Services Research
Background:
- Experts recommend left heart catheterization (LHC) for uncomplicated ischemic heart disease.
- Right heart catheterization (RHC) is reserved for specific indications.
- Some centers routinely perform combined cardiac catheterization (CCC).
Purpose of the Study:
- To examine rates of CCC for uncomplicated ischemic heart disease.
- To identify hospital characteristics associated with high CCC rates.
- To determine the justification and impact of CCC.
Main Methods:
- Analysis of 1992-1993 Pennsylvania Medicare claims (n=41,180).
- Examined CCC rates across 73 hospitals.
- Multivariable modeling and case reviews of high-rate hospitals.
Main Results:
- 34% of procedures were CCC, with rates varying from 2% to 98% between hospitals.
- High CCC rates associated with cardiology fellowship programs and eastern PA location.
- Planned revascularization was the most common justification (44%), not a specific RHC indication.
Conclusions:
- Significant variation exists in CCC practice, linked to teaching status and geography.
- Commonly cited justification (planned revascularization) is not a specific indication for RHC.
- RHC findings rarely altered management in reviewed cases.
Purpose:
Experts recommend left heart catheterization alone to evaluate uncomplicated ischemic heart disease, reserving right heart catheterization for specific indications. Yet some centers routinely perform combined cardiac catheterization (left heart catheterization and right heart catheterization together).
Subjects And Methods:
Using 1992-1993 Pennsylvania Medicare claims for cardiac catheterizations (n = 41,180), we examined rates of combined cardiac catheterization for patients with uncomplicated ischemic heart disease for each hospital (n = 73) that performed catheterizations. We compared combined cardiac catheterization rates among hospitals and developed a multivariable model to identify hospital characteristics associated with high combined cardiac catheterization rates. A random sample of cases from the 10 hospitals with the highest combined cardiac catheterization rates were reviewed to determine justification, complications, and results of combined cardiac catheterization.
Results:
Of the 41,180 cardiac catheterizations, 14,177 (34%) were combined procedures. Among hospitals, combined cardiac catheterization rates varied from 2% to 98%. Hospital characteristics associated with high combined cardiac catheterization rates included having a cardiology fellowship program (relative risk [RR] 1.7, 95% confidence interval [CI] 1.1-2.7), location in eastern Pennsylvania (RR 2.5, 95% CI: 1.8-3.5), and volume of catheterizations performed (RR 0.95, 95% CI: 0.91-0.99/100 procedures). For reviewed cases, the most common justification for combined cardiac catheterization was planned revascularization (44%), which is not a specific indication. Only 49% of cases had at least one specific indication for right heart catheterization (range by hospital, 30%-74%). The abnormal findings on the right heart catheterization rarely appeared to change management.
Conclusion:
There is wide variation in the practice of combined cardiac catheterization, which appears to be related to teaching status and geographic location. The most common justification for the procedure was planned revascularization, which is not one of the specific indications supported by current literature.