Guidelines versus reality: is coronary stent application in three-vessel disease standard or the exception?

Abstract

The national guidelines for treatment of chronic coronary heart disease (CHD) recommend surgical coronary aortic bypass grafting (CABG) rather than percutaneous coronary intervention (PCI) for patients with a coronary three-vessel disease. The epidemiology of three-vessel CHD and data about the application of different revascularisation strategies raise suspicion of deviation from the guidelines in the treatment of those patients. Claims data containing records of almost 10 million patients of the largest German statutory health insurance fund (Techniker Krankenkasse) were utilised to measure adherence to the guidelines for treatment of groups of patients with one-, two-, and three-vessel CHD, respectively. The impact of age, sex, and comorbidity on each patient's revascularisation procedure was investigated as well. There was no significant difference in the rate of PCI between the groups. In conclusion, the hypothesis that patients with a coronary three-vessel disease are not always treated according to the recommendations of the national guidelines could not be disproved by this study. Finally, the results of this study suggest that the best revascularisation strategy for each patient with two- and three-vessel disease should be decided upon by an interdisciplinary discussion between both cardiologists and cardiac surgeons.

Methods for assessing guideline adherence for invasive procedures in the care of chronic coronary artery disease: a scoping review

“… 19–26 28–30 In one study, specific procedure codes and diagnoses within the utilised claims data were resorted. 27 …”

“…19-26 28-30 In one study, specific procedure codes and diagnoses within the utilised claims data were resorted. 27 The studies' definitions of guideline adherence were based on recommendation classes/grades (used in USA, German and European guidelines) or levels of recommendation strengths (used in British guidelines). Recommendation classes/grades or levels of strengths indicate an estimate of the size of treatment effect that takes into account risks and benefits and evidence of and/or agreement on the effectiveness of a procedure.…”

“…Only one study reported a prespecified allocation rule for cases of an ambiguous assignment (ie, where a patient was assigned to more than one recommendation class). 27 In cases where guideline criteria had not been explicitly defined, four studies used a priori definitions of these criteria for an explicit assignment (eg, evidence of ischaemia, morbidity risk). 22 23 29 30 Quantification of guideline adherence Estimating the proportions of patients with adherent or non-adherent care, nine of the studies used a binary approach.…”

Guideline adherence in speech and language therapy in stroke aftercare. A health insurance claims data analysis

“…To our knowledge, no study has yet explicitly and comprehensively analysed whether and to what extent the provision of aftercare SLT adheres to current guidelines regarding the rehabilitation of aphasia, dysarthria and dysphagia after stroke. The analysis of health insurance claims data has been successfully applied previously to investigate guideline adherence and the influence of patient characteristics, for instance in patients with chronic coronary heart disease and peripheral arterial disease [ 60 , 61 ]. There were attempts in Japan to use claims data to develop quality indicators for stroke treatment [ 62 ].…”

Relationship Between High-Sensitivity C-Reactive Protein and Long-Term Outcomes in Elderly Patients With 3-Vessel Disease

“…Coronary artery disease (CAD) is a leading threat to public health, and 3-vessel disease (TVD) accounts for approximately one-third of all cases in this era of population aging. 1,2 Revascularization is important, and guidelines recommend that timely scoring models like the SYNTAX score (SS) should be applied for anatomical evaluation and decision-making during hospitalization. 3,4 However, various factors besides anatomical severity are involved in decision-making.…”