Dissemination and Adoption of Comparative Effectiveness Research Findings When Findings Challenge Current Practices. Clinical-Practice Context

01/01/2013

Treatment guidelines for patients with stable coronary artery disease (CAD) recommend an initial strategy of intensive medical therapy along with risk-factor reduction and initiation of lifestyle interventions, collectively known as optimal medical therapy (OMT). However, over the past 30 years, percutaneous coronary intervention (PCI) has increasingly been used as an initial strategy for patients with stable CAD. Approximately 85 percent of all PCI procedures are performed on patients with stable CAD (Boden, O’Rourke, et al., 2007); the remaining 15 percent are performed on patients with acute coronary syndrome (ACS), an emergency condition. PCI is also indicated for the relief of angina (chest pain); however, a large percentage of patients who undergo elective PCI are asymptomatic (Diamond and Kaul, 2007).

The increase in the use of PCI for patients with stable CAD appears to have been prompted by a variety of factors. Cardiologists may have extrapolated from the successful use of PCI for ACS (Boden, 2007). Although the procedure carries some complication risks, including mortality, these risks are generally perceived to be quite low (Lin, Dudley, et al., 2007). The introduction of intracoronary drug-eluting stents may have further encouraged the use of PCI in stable CAD patients by lowering the risk of restenosis. Other technological innovations, including new screening tests for CAD, may have increased the number of patients diagnosed with the condition. Studies show that these tests are often performed for patients who are asymptomatic (Diamond and Kaul, 2007; Lin, Dudley, et al., 2007).

Studies have documented wide variations in PCI use associated with patients’ sex and race and between geographic regions, suggesting that referral and treatment decisions may be influenced by factors other than clinical parameters (Lin, Dudley, et al., 2007). Financial incentives are likely to be a potent driver of PCI utilization. The Medicare fee-for-service payment schedule provides generous incentives for PCI, while reimbursement for the management of OMT is relatively less well compensated.

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