Clinical InvestigationIntervention CardiologyUse and overuse of left ventriculography
Section snippets
Patient population
All adults enrolled in Aetna health benefits plans and undergoing cardiac catheterization from January 1 to December 31, 2007, were included (n = 96,235). Cardiac catheterization was defined as any of the following International Classification of Diseases, Ninth Edition (ICD-9) procedure codes (3722, 3723, and 8853-8858) or Current Procedural Terminology (CPT) codes (93510, 93511, 93555, 93543, 91920, 93539, 93540, 93545, 93556, and 93508). Stanford University Institutional Review Board
Results
A total of 96,235 patients underwent coronary angiography. The mean age was 62.0 ± 13 years, and 61% were male. Other baseline clinical characteristics are present in Table I. Out of all patients who underwent coronary angiography, left ventriculography was performed in 78,705 (81.8%). Most subgroups had >80% usage rates, including 64% of those with a prior history of renal failure (Table I).
Discussion
The primary finding from this study is that left ventriculography was performed as a routine “add-on” with most of the cardiac catheterizations and that the frequency of its use was actually increased when no new information was likely to be obtained. The findings raise concerns that there is substantial overuse of left ventriculography, with implications for cost of care and patient morbidity.
Summary
In an analysis of >96,000 patients undergoing cardiac catheterization in 2007, we found that left ventriculography was concomitantly performed 81.8% of the time. Left ventriculography was performed at an extremely high frequency regardless of patient characteristics and was performed even more often if an alternative imaging modality had been recently completed. New clinical practice guidelines should be considered to decrease the overuse of this invasive test.
Disclosures
Funding Sources: This work was funded by internal funds from Stanford, the Palo Alto VA Healthcare system, and Aetna. This was an investigator-initiated study proposed by Drs Witteles, Knowles, Perez, and Heidenreich to Aetna. Through Drs Spettell and Brennan and Mr Morris, Aetna did participate in some aspects of the collection, management, and analysis of the data. Dr Knowles was supported by an AHA Fellowship grant. Dr Heidenreich is supported by a grant from the Veteran Administration's
Acknowledgements
The authors would like to thank Dr Jerome P Kassirer for helpful initial discussions regarding the project and Drs Andrew Baskin (Aetna) and William Fearon (Stanford) for helpful comments on the final manuscript.
References (21)
- et al.
The use of biplane angiocardigraphy for the measurement of left ventricular volume in man
Am Heart J
(1960) - et al.
Usefulness and limitations of radiographic methods for determining left ventricular volume
Am J Cardiol
(1966) - et al.
Changing trends in the evaluation of ejection fraction in patients hospitalized with acute myocardial infarction: the Worcester Heart Attack Study
Am Heart J
(2008) - et al.
Accuracy and precision of angiographic volumetry methods for left and right ventricle
Int J Cardiol
(1996) - et al.
Two-dimensional echocardiographic measurement of left ventricular ejection fraction: prospective analysis of what constitutes an adequate determination
Am Heart J
(1982) - et al.
Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality
Am J Med
(1997) - et al.
Contrast nephropathy in azotemic diabetic patients undergoing coronary angiography
Am J Med
(1990) - et al.
Complete heart block during retrograde left-sided cardiac catheterization
Am J Cardiol
(1989) - et al.
ACCF proposed method for evaluating the appropriateness of cardiovascular imaging
J Am Coll Cardiol
(2005) - et al.
ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI)
J Am Coll Cardiol
(2005)
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A. Michael Lincoff, MD, served as guest editor for this article.
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These authors contributed equally to this article.