Coronary Revascularization Procedures Underused in the UK
Percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) are substantially underused in the UK, and this results in adverse outcomes, according to a report in the March 1st issue of The New England Journal of Medicine.
Dr. Harry Hemingway, from the Kensington & Chelsea and Westminster Health Authority, London, and colleagues compared the clinical outcomes of patients treated either with PTCA, with CABG or medically after angiography.
A nine-member expert panel rated the appropriateness of PTCA and CABG on a 9-point scale, and the researchers used these ratings to evaluate the treatment of 2552 patients from three London hospitals who were followed for a median of 30 months after angiography.
For the 908 patients for whom PTCA was indicated, 34% received medical treatment. These medically treated patients “were more likely to have angina at follow-up,” the investigators report, than those who did in fact receive PTCA.
Similarly, 26% of the 1353 patients for whom CABG was indicated received only medical treatment, and these patients were more likely to die or have a nonfatal myocardial infarction and angina than those who received CABG, Dr. Hemingway’s team found.
Dr. Hemingway and colleagues suggest that “the integration of explicit measures of appropriateness into routine clinical decision making may improve the quality of care.”
Commenting on the report, journal editorialist Dr. Paul G. Shekelle, from the Greater Los Angeles Veterans Affairs Healthcare System, agrees that establishing appropriateness criteria is important in making decisions about major medical procedures.
“But,” he stresses, “the continued quest for better criteria should not delay the application of existing criteria in clinical practice. To wait until the criteria are perfect is to condone the status quo, in which 20% to 40% of patients do not receive medical procedures from which they would benefit substantially. Surely we can do better than this.”
N Engl J Med 2001;344:645-654,677-678.
