Author + information
- †Division of Cardiovascular Medicine, Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- ‡Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
- §Cardiology Division, VA Boston Healthcare System, Boston, Massachusetts
- ↵∗Reprint requests and correspondence to:
Dr. Karen Joynt, Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115.
Cardiovascular medicine has the dubious distinction of being the clinical area in which racial and ethnic disparities in access to care, as well as sex-based, economic, and geographic disparities, are most thoroughly documented (1). Prior studies have shown that African-American patients (2), women (3,4), patients with Medicaid insurance (5), and patients in rural areas (6,7) are less likely to receive recommended cardiovascular treatments and may have worse cardiovascular outcomes. Indeed, underuse of guideline-based care in vulnerable populations has been shown time and time again to be a persistent and pervasive problem within medicine in general, and within cardiovascular medicine in particular.
In this issue of the Journal, however, Chan et al. (8) examine the flip side of poor quality: overuse. The investigators used the National Cardiovascular Data Registry CathPCI Registry database to examine differences in the inappropriate use of percutaneous coronary intervention (PCI) by race, sex, insurance status, and rurality. One might assume that if members of racial and ethnic minority groups, impoverished individuals, women, and individuals living in rural areas receive generally worse care overall, then they would not only be the victims of underuse of services, but would also suffer from the effects of overuse.
Instead, the authors identified a different story, in fact, quite the opposite story. The patients most likely to receive inappropriate PCI were patients who were white (9% higher odds), men (8% higher odds), and those at suburban hospitals (10% higher odds). Patients with no insurance, public insurance, or Medicare insurance were less likely to receive inappropriate PCI, as were patients at rural hospitals. In each case, patterns of overuse of PCI were diametrically opposed to prior research on patterns of underuse.
This study is consistent with prior work demonstrating that overuse of technologies or procedures may contribute to racial disparities in care. In two smaller studies using data from the early 1990s and a slightly different set of appropriateness criteria it was similarly found that whites were more likely to undergo inappropriate PCI than blacks, and it was found that this explained some, although not all, of the racial disparities in use of this procedure (9,10). Furthermore, in these studies, overuse was more frequent in men. A study of renal transplantation candidates demonstrated that whites were more likely than blacks to be inappropriately listed for transplantation (30.9% of inappropriate candidates vs. 17.4%) and even to undergo transplant, despite contraindications (10.3% vs. 2.2%) (11).
So is this really a problem? Is overuse as “bad” as underuse? This is actually a somewhat difficult question to answer. The economic consequences of overuse of PCI are straightforward: needless spending for no clinical benefit. The clinical consequences however, are more complex. Inappropriate PCI surely leads to unnecessary exposure to risk, such as bleeding, access-site complications, stroke, and coronary complications (e.g., peri-procedural myocardial infarction, dissection, and distal embolism) (12–14). However, given that in general, the patients on whom procedures are overused are a healthier group undergoing elective procedures, their outcomes are still good. In fact, prior studies have shown that hospitals' proportion of inappropriate PCIs is not associated with clinical outcomes including in-hospital mortality and bleeding (15). Thus, the clinical consequences of overuse remain largely invisible, at least on a population level.
Therefore, this remaining issue points out the major limitation to this study: the lack of a broader denominator. We are “missing” the non-PCI patients from the National Cardiovascular Data Registry database, and therefore it is difficult to know what the right rates of PCI really are in these populations. It is quite feasible — and given the wealth of data suggesting that PCI is underused in women and blacks (2–4), even likely — that there is concurrent underuse and overuse, and that the optimal use of this important procedure lies somewhere in between. Without knowing the true denominator, it is impossible to calculate a net “clinical benefit” that takes each source of error into account. This represents an important area of future research.
Despite this limitation, however, this article represents a very important contribution to the literature. These findings are important because they make clear the types of interventions that are most (and least) likely to be effective in improving the overall quality of care delivered for cardiovascular disease. Programs aimed at simply increasing the appropriate use of cardiac procedures, such as cardiac catheterization and PCI, will not, in and of themselves, do enough to improve quality, and in fact, they may widen disparities by increasing use in white patients and men even further. Programs aimed at simply decreasing the inappropriate use of PCI will not lead to optimal quality, and again, in doing so could potentially worsen disparities if black patients and women are the first for whom procedures are withheld. Both sides of the quality paradigm—underuse and overuse—must be together at the forefront of our quality improvement efforts.
According to the Agency for Healthcare Research and Quality, high-quality health care means “doing the right thing, at the right time, in the right way, for the right person—and having the best possible results” (16). Optimizing quality in cardiovascular care will take a multipronged approach aimed at both improving underuse and reducing overuse, and by doing so, has the potential to reduce healthcare disparities.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Dr. Joynt has reported that she has no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Institute of Medicine
- Chan P.S.,
- Rao S.V.,
- Bhatt D.L.,
- et al.
- Fuchs S.,
- Stabile E.,
- Kinnaird T.D.,
- et al.
- Anderson H.V.,
- Shaw R.E.,
- Brindis R.G.,
- et al.
- Bradley S.M.,
- Chan P.S.,
- Spertus J.A.,
- et al.
- ↵Agency for Healthcare Research and Quality. A Quick Look at Quality. Washington, DC: U.S. Department of Health and Human Services; 2003. Available at: http://archive.ahrq.gov/consumer/qnt/qntqlook.htm. Accessed July 29, 2013.