David C. Levin MD, Presenter: Consultant, HealthHelp Board of Directors, Outpatient Imaging Affiliates, LLC

Vijay Madan Rao MD, Abstract Co-Author: Nothing to Disclose

Laurence Parker PhD, Abstract Co-Author: Nothing to Disclose

Andrea J. Frangos MPH, Abstract Co-Author: Nothing to Disclose

In April 2007, the widely anticipated COURAGE trial was published. It showed that in patients with stable coronary artery disease, percutaneous coronary intervention (PCI) essentially produced no better outcomes at a median of 4.6 years of followup than optimal medical therapy. This strongly suggested that PCI was unnecessary in many patients who had previously undergone it. We felt it would therefore be of interest to determine whether the rate of use of PCI by cardiologists declined after the COURAGE results became known.

The nationwide Medicare Part B databases for 2000-2010 were used. These databases provide procedure volume and other administrative data for all codes in the CPT-4 manual. The surgical CPT codes for percutaneous transluminal angioplasty, stent placement, and atherectomy of the coronary arteries were selected. Medicare specialty codes were used to identify cardiologists. Procedure volumes for these 3 types of PCI were aggregated. Utilization rates per 100,000 Medicare beneficiaries by cardiologists were calculated for all study years.

Cardiologists performed 89% of all PCIs in 2000 and 95% in 2010. Their PCI utilization rate per 100,000 Medicare beneficiaries was 983 in 2000, rising to 1258 in 2004, for a compound annual growth rate during those years of 6.4%. Their utilization rate then remained essentially flat during 2005 and 2006. But in 2007, the year in which the COURAGE trial results were published, cardiologists’ utilization rate of PCI dropped to 1091, a decrease of 13% compared with 2006. During the next 3 years, there was a slight further decline, reaching a rate of 1069 in 2010.

The COURAGE trial has had a major impact on the use of PCI by cardiologists. It led to a sharp drop (13%) in a single year, and there has been no subsequent rebound. The magnitude of this drop is even more impressive, given that over half of all PCIs are performed for unstable or acute coronary syndromes, and the indications for these were not altered by the COURAGE trial. Cardiologists deserve credit for reducing the use of these invasive and expensive procedures in response to data proving that they do not improve outcomes in a large patient group.

not applicable

Levin, D, Rao, V, Parker, L, Frangos, A, Did the Utilization of Percutaneous Coronary Interventions by Cardiologists Decrease after Publication of the Influential COURAGE Trial?.  Radiological Society of North America 2012 Scientific Assembly and Annual Meeting, November 25 - November 30, 2012 ,Chicago IL. http://archive.rsna.org/2012/12022913.html