Appropriate use outliers: Minor variation or problem?

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Kaitlyn Dmyterko, senior writer

While evidence-based guidelines seek to portray the ins and outs of when and when not to perform a procedure, there are still gray areas in terms of how to treat certain patients whose indications may fall outside the guidelines. To add to these types of gray areas, hospitals also vary on cost-saving and diagnoses strategies. What could these types of variations mean for the future of clinical practice?

Whether or not PCIs are being performed appropriately and within the guidelines has been big news recently. In fact, research presented at this year's ACC.11 in New Orleans showed that one in nine elective PCI procedures were deemed “inappropriate.”

However, Gregory J. Dehmer, MD, co-author of both the study and the appropriate use criteria (AUC) for revascularization, told Cardiovascular Business that “inappropriate” may not mean that it's wrong or right; rather, it might mean that there is not enough clinical evidence to back it up. This identifies a “knowledge gap,” Dehmer said.

Of the 354,161 procedures evaluated during the study, 85 percent were deemed appropriate, 11.2 percent were deemed uncertain and 4.1 percent were deemed inappropriate.

Dehmer attributed this variation to the fact that when physicians perform elective procedures, it requires more judgment from the physicians because each patient case is unique.

Similarly, a study published this week in the Journal of the American College of Cardiology showed that positive findings of obstructive coronary artery disease (CAD) with coronary angiography had a wide variation across centers, 23 to 100 percent. In the study, researchers from Duke said that these findings could make way for further quality improvements and the development of AUC for diagnostic coronary angiography, which does not yet exist.

The researchers showed that sites with lower rates of obstructive CAD were more likely to perform these exams in patients who were younger, black, women or outpatients and had a lower Framingham Risk Score. Study author Steven R. Bailey, MD, past-president of the SCAI, told Cardiovascular Business that these types of variations reflect trends of how patients are referred for these types of tests.

Quality measures and AUC guidelines could help decrease the wide variation gaps found between hospitals. AUC will help individual facilities and interventional cardiologists identify their own procedures as appropriate, uncertain or inappropriate and understand where they are performing in comparison to the benchmarks, Dehmer said.

“In this profession, we have the privilege to regulate ourselves to make sure we are doing procedures that are in the best interest of patients in every individual patient case,” Dehmer told Cardiovascular Business. “Before appropriate use we couldn’t measure what we’re doing. Now this gives us a benchmark and we are able to work toward areas where we need improvement and then begin making those improvements.”

Do these gaps occur simply because physicians must take into consideration that the patient has become more complex and specific cases are not strategically outlined in the guidelines? Are these types of variations problematic or just minor variations?

On these topics or others, please feel free to contact me.

Kaitlyn Dmyterko, senior writer
Cardiovascular Business