Amid Soaring CAD in China, Rates of Catheterization and PCI Begin to Mount

One of the most sweeping surveys to date examining PCI in China shows that estimated national rates for the procedure increased there more than 20-fold over a 10-year period. This increase mirrors the dramatic rise in ischemic heart disease in China and speaks to the pace of change taking place in the world’s most populous country—a shift with profound implications beyond the country’s borders.

Researchers led by Xin Zheng, MD, PhD (Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China), noted that in addition to this increase in incidence, “there have been substantial changes in clinical practice, most notably, the widespread adoption of radial access and the routine use of DESs, especially domestic DESs.”

What’s needed next, authors say, is a more comprehensive approach to data gathering, performance measurement, public reporting, and quality improvement.

“Our findings can serve as a foundation to guide efforts to further improve the quality of care and allocation of resources not only for China, but also for other developing countries with a rapidly growing cardiovascular disease burden, limited medical resources, and dynamic health care systems,” they write.

Results from the China PEACE-Retrospective CathPCI study were published online in JAMA Internal Medicine on March 14, 2016.

Increasing Demand

Zheng and colleagues looked at a sample of 11,241 patients taken from 55 urban hospitals in China in the years 2001, 2006, and 2011. Over the decade-long time frame, the estimated number of patients hospitalized for coronary catheterization increased from about 26,000 to more than 450,000, and the rate of PCI increased from about 9,600 to more than 200,000.

Several trends emerged about the characteristics of patients undergoing catheterization and PCI, including the fact that in both 2001 and 2011 approximately 60% of stable patients undergoing coronary catheterization had nonobstructive CAD.

An increasing number of PCIs were performed on patients with NSTEMI between 2001 and 2011. Meanwhile, the proportion of implanted stents that were DES also rose.

One of the greatest changes observed over the 10-year study period was a sharp rise in radial access, a shift the researchers say is “supported by studies demonstrating higher patient satisfaction, reduced length of stay and lower risk of procedural complications.” Indeed, between 2011 and 2001, they observed decrease in median length of hospital stay. However, there was no reduction in in-hospital mortality.

However, patients did have a 47% lower adjusted risk of any bleeding in 2011 compared with 2001 and a 77% lower adjusted risk of access bleeding (P for trend < 0.001 for both).

An exploration of quality metrics for the procedures revealed “critical quality and documentation gaps”. Specifically, the researchers noted that in 2011 information on hospital arrival time and balloon dilation time—two key elements for calculating door-to-balloon time—was absent in 3.0% and 0.5% of patient records, respectively. More than half of patient records did not include documentation on whether or not the PCI procedure was successful, and more than one-third lacked information about discharge medications.

Zheng and colleagues note that since the data in this study only extend through 2011, the patterns may not reflect current practices. However, based on these results, it is clear that “changes in procedural volume have not been matched by the development of systems to ensure that the care delivered to these patients is evidence-based, safe and efficient,” they write.

Wider Implications

In an accompanying editorial, David Blumenthal, MD (The Commonwealth Fund, New York, NY), and colleagues echo concerns about the lack of quality metric information, including the absence of data on use of guideline-directed medical therapy prior to PCI, which they say is “a key indication of appropriateness.” These gaps in documentation make it difficult to draw conclusions about the appropriateness of these procedures from this study, they note.

That said, studies like this one have wider implications to the healthcare community and to interventional cardiologists in particular because they help shed light on practice patterns in another country, Blumenthal told TCTMD in an interview. In this case, he said, the country has the largest up-and-coming market in the world.

“As the number of PCIs goes up in China, the demand for new devices and advances in devices is going to soar,” Blumenthal said.

“If China continues to modernize, the use of those devices is going to spread into rural areas,” he observed, “where there are still 1 billion Chinese that are probably very minimally serviced for invasive cardiology procedures.” As noted by the study authors, the increase in PCI observed here only represents the urban populations of China, which amount to roughly one-third of its total population.

Finally, Blumenthal pointed out that these data should be of importance to physicians, no matter where they live.

“The ability of China to provide basic modern services to its population is going to be very important over time to its stability,” Blumenthal said. “The stability of China, its economic well-being, and political stability are going to be very important factors in the quality of life of Americans, Europeans, South Asians, South Americans, and Africans for the foreseeable future. The ability of the Chinese to get health services that are affordable to its people and meet their demand for good services is a major part of the social safety net going forward in China and will affect the stability of the regime and the way China behaves as a member of the international community.”

• Zheng X, Curtis JP, Hu S, et al. Coronary catheterization and percutaneous coronary intervention in China. 10-year results from the China PEACE-Retrospective Cath PCI Study. JAMA Intern Med. Epub ahead of print.

Related Stories:

• New PCI Performance Measures Issued to Improve Quality of Care
• Study Suggests PCI Use Exceeds ACC-AHA Guideline Recommendations