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Guidelines call for noninvasive testing to document ischemia prior to elective PCI, but new research indicates that this is usually not done in Medicare patients.

Guidelines from various medical groups call for noninvasive testing to document ischemia prior to elective percutaneous coronary intervention (PCI), but new research indicates that this is usually not done in Medicare patients.

In the study of nearly 24,000 patients, just 44.5 per cent underwent stress testing within the 90 days before PCI. In fact, the testing rate was half that figure in some hospital regions, according to the report in the Journal of the American Medical Association for October 15.

Guidelines released in 2005 by the American College of Cardiology, American Heart Association, and the Society for Cardiovascular Angiography and Intervention state that in patients with stable angina, any vessels to be treated with PCI need to shown to be "associated with a moderate to severe degree of ischemia on non-invasive testing." Moreover, research has confirmed that outcomes are improved with adherence to this recommendation.

How often this recommendation is actually followed, however, is unclear, senior author Dr. Rita F. Redberg from the University of California, San Francisco, and colleagues note.

Stress testing rates ranged from 22.1 per cent to 70.6 per cent depending on the hospital region, the report shows.

Female gender, age of 85 years or older, a history of heart failure, and prior cardiac catheterization were associated with adjusted odds ratios of 0.91, 0.83, 0.85, and 0.45, respectively, of undergoing stress testing within 90 days of PCI.

Treatment by a physician who performed 150 or more PCIs annually was also associated with reduced likelihood of stress testing, with an odds ratio of 0.84.

Conversely, a history of chest pain and black race increased the likelihood of stress testing (ORs 1.26 and 1.26, respectively).

No hospital factors correlated with the likelihood of stress testing, the report indicates.

"Our findings," Dr. Redberg's team states, "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."

"The analyses that were performed leave the clear impression that referral for PCI was influenced less by objective evidence of ischemia than by incidental factors," Dr. George A. Diamond and Dr. Sanjay Kaul from the University of California, Los Angeles, comment in a related editorial. "The wide geographic variation in rates of stress testing before PCI further supports this conclusion."

JAMA 2008;300:1765-1773,1817-1819