Cardiovascular Rounds

Our take on the big PCI controversy

By Megan Tooley, Aaron Mauck, and Sebastian Beckmann

ORBITA, the double-blind, randomized control trial on percutaneous coronary intervention (PCI) in stable angina, revealed a worrying result: Researchers found that PCI was no better than a placebo in relieving participants' chest pain.

Both patient groups in the study underwent a rigorous medical optimization process, then half received a drug-eluting stent while the other half went through a sham intervention. While both cohorts saw an improvement in exercise capacity, reported chest pain, and quality of life In the six-week follow-up period, the PCI group performed no better than the placebo group.

Since then, we've seen a wave of reactions in publications ranging from the New York Times to The Lancet. The implication is clear: If borne out by future research, these results could meaningfully change clinical practice.

But the potential impact on a CV program is murkier. We ran an analysis on all PCI Medicare fee-for-service claims from Q3 2016 through Q1 2017 and found that of the 172,000 claims, 10.3% included a diagnosis code for stable angina. That figure is probably a high estimate of at-risk volumes, as it includes any claims with a chest pain diagnosis code, capturing patients with chest pain who received PCI for other reasons. Nevertheless, a shift in clinical guidelines could have a serious impact on cardiovascular revenues already under pressure. This is especially important in the context of declining interventional volumes and an increasing emphasis on medical management.

Advisory Board's take

Regardless of the ultimate impact the ORBITA study may have on the overall rate of PCI interventions, it is important for CV programs to stay up-to-date with clinical guidelines and make adjustments to how cases are selected and treated based on the most recent findings. This will help ensure that programs can anticipate future appropriateness scrutiny and install mechanisms to ensure appropriateness before these become required. In the wake of this study, CV programs should carefully consider their current strategy for the treatment for stable angina patients, and hold honest conversations with providers about the results of the study and its implications for treatment choice.

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