JAMA: Doctors are skipping stress tests prior to elective PCI

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Some cardiologists have stopped relying on noninvasive stress tests before stenting. Image Source: www.tomographyblog.com  

Researchers have found that Medicare recipients who undergo elective percutaneous coronary intervention (PCI) often do not get the recommended stress tests to confirm the surgery is warranted, according to a study published in the Oct. 15 issue of the Journal of the American Medical Association.

PCI approximately costs Medicare $10,000 to $15,000 per procedure, according to the study’s authors. Previous studies, such as the COURAGE trial, have suggested that many stable patients with chest pain can get about the same level of relief with standard drug therapy, but at far lower cost.

"This means, in most patients who are not having a heart attack, a noninvasive stress test should take place before physicians make the decision to go forward with invasive procedures like stenting and angioplasty," said lead author Grace Lin, MD, associate adjunct professor of medicine at the University of California, San Francisco.

Lin and colleagues conducted a retrospective, observational cohort study to see if doctors who are performing PCI surgeries follow stress test ordering practice guidelines to determine whether the procedure is needed.

For the study, stress tests included stress echocardiography, exercise treadmill or pharmacological stress and myocardial nuclear imaging. For imaging stress tests, patient had to have had both a stress component and an associated imaging component within a one-day window, the authors noted.

In examining insurance claims data from a 20 percent random sample of 2004 Medicare fee-for-service beneficiaries aged 65 years or older who had an elective PCI, the researchers found that fewer than half of the patients took a stress test on a treadmill within 90 days of their elective surgery. This rate varied significantly depending on the hospital patients were referred to, with rates ranging from a low of 22.1 percent to a high of 70.6 percent, they noted.

Lin said that older doctors and those who perform more elective PCIs tended to order fewer stress tests. Since the rates differed widely by geography, she said that local practice patterns also played a role in the decision to do the test.

The team also found that patient characteristics were associated with the likelihood of a patient receiving a stress test prior to PCI. Females, age 85 years or older with co-existing illnesses such as rheumatic disease, chronic obstructive pulmonary disease, congestive heart failure and coronary artery disease had a decreased likelihood of stress testing prior to PCI. Yet, black patients with a history of chest pain had an increased likelihood of a stress test prior to PCI.

Lin and colleagues concluded that guidelines for PCI call for documenting ischemia prior to PCI in the vast majority of patients with stable CAD; however, data suggest that this is not being done consistently.

“Assessing whether PCI is being performed in appropriately selected patients is crucial to providing high-quality, patient-centered medical care in light of evidence that patients in regions providing high-intensity care do not have better (and sometimes have worse) outcomes than those in regions providing low-intensity care,” the authors wrote.
“Our findings highlight an opportunity for improvement in the care of patients with stable CAD and suggest that current proposals to restructure Medicare payment to reward hospitals and physicians who adhere to guidelines would improve the safety and delivery of healthcare to Medicare beneficiaries while decreasing Medicare expenditures on costly and inappropriate procedures,” they concluded.

The Blue Shield of California Foundation funded the study.