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Most Patients Do Not Undergo Recommended Stress Test to Confirm Need for Elective Angioplasty CHICAGO -- October 14, 2008 -- A majority of Medicare patients with stable coronary artery disease (CAD) who underwent an elective percutaneous coronary intervention (PCI) did not have a recommended stress test performed to confirm the necessity of the procedure, according to a study in the October 15 issue of the Journal of the American Medical Association. Grace A. Lin, MD, University of California, San Francisco, San Francisco, California, and colleagues conducted a study of Medicare beneficiaries undergoing elective PCI to determine the frequency with which stress testing was performed prior to PCI. The researchers analysed claims data from a 20% random sample of 2004 Medicare fee-for-service beneficiaries aged 65 years or older who had an elective PCI (n = 23,887). The researchers found that, of this study group, 44.5% (10,629) of patients underwent stress testing within the 90 days prior to elective PCI. There was significant geographic variation in the rate of stress testing by hospital referral region, with rates ranging from a low of 22.1% to a high of 70.6%. The rate of stress testing did not correlate with the volume of PCI procedures performed in the hospital referral region. Patients who had a prior cardiac catheterisation were less likely to undergo stress testing prior to elective PCI. Female sex, age of 85 years or older, and having coexisting illnesses such as rheumatic disease, chronic obstructive pulmonary disease, congestive heart failure, and CAD were associated with decreased likelihood of stress testing prior to PCI. Conversely, patient characteristics associated with an increased likelihood of a stress test prior to PCI were black race and having a history of chest pain. Patients of physicians who performed a higher volume of PCI procedures had slightly lower rates of stress testing. No hospital characteristics were associated with receipt of stress testing. "Guidelines for PCI call for documenting ischaemia prior to PCI in the vast majority of patients with stable CAD; however, our data suggest that this is not being done consistently," the authors wrote. "Assessing whether PCI is being performed in appropriately selected patients is crucial to providing high-quality, patient-centred medical care in light of evidence that patients in regions providing high-intensity care do not have better outcomes than those in regions providing low-intensity care." In an accompanying editorial, George A. Diamond, MD, and Sanjay Kaul, MD, of Cedars-Sinai Medical Center and University of California, Los Angeles, Los Angeles, California, wrote that properly designed economic incentives might balance competing influences regarding the use of PCI. "The Centers for Medicare and Medicaid Services, for example, might set reimbursement for evidence-based care at a higher level than for non-evidence-based care. Thus, a cardiologist performing PCI for a patient with objective evidence of ischaemia despite an appropriate intensity of medical therapy would be paid more than for the same patient without such evidence. Unlike 'pay-for-performance,' these evidence-based reimbursement incentives target individual physician decisions rather than aggregate patient outcomes, are based on empirical data rather than consensus opinion, and are relatively large in size and immediate in effect." SOURCE: Journal of the American Medical Association E-mail this page to a friend or colleague! To print, use this version