Variation in patients’ perceptions of elective percutaneous coronary intervention in stable coronary artery disease: cross sectional study

Despite the publication and wide-spread dissemination of the unique and important messages from seminal COURAGE trial (A landmark, game-changer study) published seven years ago (1).The persistent gap between the scientific facts and its applicability is amply highlighted in the recent study by Faraz Kureshi et al.(2) In the real- life practice ,even in developed countries with prevalent medical malpractice suits; almost half of Percutaneous coronary interventions(PCIs) done in patients with stable angina are inappropriate or of uncertain appropriateness,(3) depicting prevalent medical malpractices or "oculostenotic reflex".(4)
In the era of contemporary technology- driven health-care delivery systems, in particular mushrooming of private high-tech health-care facilities ( particularly in low- and medium- income countries with less prevalent medical malpractice suits); the motivation for the delivery of expensive services ( even many times inappropriate) is not uncommon.
"It is better to light a candle than curse the darkness" is a famous quotation from Eleanor Roosevelt ( The former first- lady, the wife of former US President Franklin D Roosevelt). As the problem of inappropriateness is gigantic. The concerted efforts are the need- of- the- hour in order to contain this pernicious practice observed even in one of the best hospitals around the world. We propose the following practices to prevent inappropriateness in the expensive treatment ( myocardial revascularization either PCIs or coronary artery bypass surgery) in patients with stable coronary artery disease ( Quaternary prevention(5)):
1.At the level of Cardiology practice :
a) Heart -team approach to the patient with stable coronary artery disease ( stable CAD) before myocardial revascularization.
b) Before considering coronary angiography in stable CAD , definite indication for coronary angiography must exist as per recent guidelines (6).Appropriate- use- criteria( AUH) form also to be duly filled-in.
c)No ad hoc PCIs in stable CAD: After the diagnostic coronary angiogram ,the patient must return to his/her room or ward ( PCI should not be done in the same sitting).The heart-team approaches the patient and the patient along with his/her family members/care-givers are involved in the decision making with the full informed consent.
d) The informed consent form must be in the lay-man language of the patient. The form must have not only the procedure details and its complications , but it must also include the intended benefit of only relief in angina ( PCI is indicated in event of either failure of optimal anti-anginal therapy to control angina or optimal medical therapy is not possible for one reason or the other) and not prolongation of the life and no prevention of acute myocardial infarction in future( except in left main stem and severe triple vessel disease) . The form must also contain alternatives.
e) The patient and his/her family members must be thoroughly educated using videos and relevant educational material ( which is easier for them to comprehend) ,they should be given sufficient time to comprehend the facts and they should be motivated to address their concerns, questions or queries. The patient along with his/her family members must be involved in the final process of decision making, emphasizing that opportunity for the revascularization always exists at any point in time in the natural history of their illness.
f) It is preferable that principal operator ( if needed, along with his team of assistant doctors and nurses) obtains the informed consent.
2. At the level of medical insurance companies: A thorough scrutiny must be made before giving the permission and/or before reimbursement for the myocardial revascularization for the patients with stable CAD.
3. Practices at health-care facility level:
a) Inappropriate expenditures must be contained and health-care providers should not be influenced in favor of inappropriate/premature profitability .
b) An independent health-care worker must assess the comprehension and understanding of the patients about the details in the informed consent form
4. At the level of health related policy- makers.
a) The practice of offering the incentives ( either cash or inordinate kindness) to the referring health-care providers must be discontinued ( if it exists in a given system) . It must be declared illegal and an unambiguously drafted law must be enforced to bring the violators to justice promptly.
b) There should be international /national registry for myocardial revascularization for patients with stable CAD.
5. At the level of medical profession licensing and governing bodies:
a) They must have the system of regular audits to check the informed consent forms and actually how the consent is being obtained from the patients and to see that AUC forms are duly filled-in in each patient before myocardial revascularization.
6. At the level of health-care system accreditation bodies like Joint Commission International (JCI) etc.:
a) They must ensure that contents of the informed consent forms are comprehensive and the process of obtaining the informed consent , of duly filling-in AUC forms exists .This should be made obligatory for the hospitals having facility for myocardial revascularization.
7. At the level of guidelines developing scientific bodies like American Heart Association ( AHA ) etc.:
a) It is important to define the scope of quaternary prevention guidelines, particularly in patients with stable CAD.
b) The standards for informed consent forms must be developed.
8. At the community -level: Regular educational sessions and health- fares to educate the people and public about the common diseases like CAD is highly useful and recommended.
9.At the level of international bodies like World Heart Federation ( WHF) or World Health Organization( WHO): They must set the goals at the global level to reduce inappropriateness in PCIs in patients with stable CAD ; around 20% per year so that by the end of five years this practice is almost eliminated around the globe. The goals must be precise and should be communicated to all governments with its blueprints.

Conflict of interest: None
References:
1.Boden WE,O' Rourke RA,Teo KK,et al.Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med.2007;356:1503-1516
2.Kureshi F,Jones PG,Buchanan DM,et al.Variation in patients' perceptions of elective percutaneous coronary interventionsd in stable coronary artery disease: Cross section study.BMJ 2014 349:g 5309
3.Chan PS,Patel MR,Klein LW ,et al.Appropriateness of percutaneous coronary intervention. JAMA.2011;306(1):53-61
4.Ling GA, Dudley Adams .Fighting the "oculostenotic reflex".JAMA Intern Med.2014;174(10):1621-1622
5.Gervas J,Starfield B,Heath I . Is clinical prevention better than cure? Lancet.2008;372:1997-99
6.2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused update of guideline for the diagnosis and management of patients with stable ischemic heart disease.Stephen D.Finn et al. J Am Coll Cardiol.2014;64(18):1929-1949
Rajeev Gupta,
rajeevsavita.gupta@gmail.com