A Targeted Approach to Reducing Overutilization: Use of Percutaneous Coronary Intervention in Stable Coronary Artery Disease

Abstract

Overutilization, defined as use of unnecessary care when alternatives may produce similar outcomes, results in higher cost without increased value. Overutilization can be understood by focusing on settings where overuse is obvious. One example is percutaneous coronary intervention (PCI) in chronic stable angina. PCI is a potentially lifesaving procedure in an acute setting, but current practice guidelines indicate low-risk patients with chronic stable angina should be treated initially with optimal medical therapy (OMT) and lifestyle modification. A decision to move from this approach to PCI should be based on severity of symptoms and degree of risk. Over the last 30 years, advances in equipment, adjunctive medical treatments, and safety have made PCI more common. Recent evidence questions the benefit of PCI in stable coronary artery disease demonstrating no reduction in overall mortality or major cardiac events compared to OMT. Despite these findings, some continue to favor aggressive PCI interventions over conservative management in low-risk situations. Patients who undergo PCI without understanding the evidence may be inappropriately reassured that PCI will reduce the need for OMT and the risk of heart attack and death. Research shows shared decision-making can result in more conservative care, particularly when patients are assessed for health literacy and counseled on clinical evidence. Overutilization of PCI can be addressed by promoting active participation in an evidence-based decision-making process, allowing the opportunity to understand the expected value of invasive procedures over OMT alone through processes that encourage physicians to incorporate shared decision making prior to PCI in non-acute situations.