Assessing the appropriate use of health care resources has been a major focus of recent efforts to improve the efficiency of the Ontario health care system. In the first study of its kind, researchers at the Institute for Clinical Evaluative Sciences (ICES) and the Cardiac Care Network of Ontario (CCN) examined the appropriate use of coronary revascularization (angioplasty and bypass surgery) in patients with stable coronary disease.
“Our study provides contemporary insights into both the underutilization and overutilization of coronary revascularization practice in Ontario. Crucially, it shows that patients who meet the appropriateness criteria and receive care get better results. This is direct evidence that appropriateness criteria can be applied in clinical practice to improve health care,” says lead author and ICES scientist Dr. Dennis Ko, also an interventional cardiologist with the Schulich Heart Centre at Sunnybrook Health Sciences Centre.
Patients who get chest pain due to severe narrowing of the arteries may require coronary revascularization—either angioplasty (inserting and inflating a balloon into a narrowed or obstructed blood vessel in the heart) or coronary bypass surgery (a healthy blood vessel from another part of the body is grafted onto the heart to circumvent a blocked artery).
Growing concerns about the potential misuse of advanced cardiac technologies and rising health care costs have rekindled interest in using evidence-based criteria to improve the appropriate use of these two surgeries.
The Variations in Revascularization Practices in Ontario (VRPO) study, a joint initiative of CCN and ICES, looked at 1,625 stable patients undergoing cardiac catheterization in Ontario between April 1, 2006 and March 31, 2007 and applied appropriateness criteria for coronary revascularizations.
The study found that:
Patients who were deemed appropriate and did not get revascularization had a 39 per cent increased risk of adverse outcomes compared with those who received treatment.
68 per cent of all coronary revascularizations (angioplasty or bypass surgery) were considered appropriate. These patients clearly benefitted from the procedures.
18 per cent of all coronary revascularizations were considered uncertain on grounds of appropriateness.
14 per cent of all coronary revascularizations were considered inappropriate.
Patients who were uncertain or inappropriate and received revascularization did not get any benefits from the procedures.
“Using the appropriateness criteria, we identified substantial underutilization and overutilization of coronary revascularization in contemporary clinical practice. Underutilization of coronary revascularization is associated with significantly increased risks of adverse outcomes in patients with appropriate indications,” says Kori Kingsbury, CEO of the Cardiac Care Network of Ontario and co-author of the study.
The study “Assessing the association of appropriateness of coronary revascularization and clinical outcomes for patients with stable coronary artery disease” appears in the Journal of the American College of Cardiology.
Author block: Ko DT, Guo H, Wijeysundera HC, Natarajan MK, Nagpal AD, Feindel CM, Kingsbury K, Cohen EA and Tu JV, for the Cardiac Care Network of Ontario's Variations in Revascularization Practice in Ontario (VRPO) Working Group.
More detailed study findings are available on the ICES website.
ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of health care issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting health care needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.
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