Prone Positioning in Awake, Nonintubated Patients With COVID-19

Abstract

as inappropriate for PCI (13% of all cases).Notably, this figure likely greatly underestimates the number of inappropriate PCIs because the authors were unable to determine if symptomatic patients had first tried and failed optimal medical management before undergoing PCI.Although robust guidelines should be expected to reduce inappropriate PCI, Howard and Desai 3 demonstrate how implementing such criteria depends on accurately reporting case characteristics (eg, the severity of coronary stenosis and symptoms) and highlight egregious examples for which the reporting was not only inaccurate but dishonest.Specifically, they investigated the association of the US False Claims Act, a law that allows whistleblowers to raise concerns of inappropriate care, with PCI volumes for patients without acute MI. 2 Between 2006 and 2016, the authors identified 8 cases of PCI-related US False Claims Act cases that became public.Compared with matched control hospitals, PCI volumes for nonacute MI decreased more from 2006 and 2016 in hospitals subject to claims of dishonest reporting (68.4% vs 81.2%; P< .001).Although the substantial decrease in PCI seen in all hospitals suggests an overall movement to a more evidence-based use of PCI, the differential decrease in hospitals that underwent investigations of false claims suggests that there is a role for the enforcement of accurate reporting of indications for PCI.It is unknown how commonly coronary stenosis is overestimated in centers that have not been targeted by False Claims cases.Despite the effect of these efforts, without quantitative, objective standards for stenosis, it is likely that some overestimation of coronary stenosis will remain. 10 Reports of continued substantial rates of inappropriate PCI provide a compelling illustration of the considerable work that remains to protect patients and the health care system from the harms and costs of unnecessary PCI.As a conservative estimate (ie, not including cases that could be averted with optimal medical management or the costs of adverse outcomes of PCIs), if the approximately 50 000 PCI cases deemed rarely appropriate by Malik et al 2 were averted at a cost of $30 000 per PCI, 11 this would produce a savings of $1.5 billion annually.However, if we extrapolate from prior work showing that greater than 50% of patients undergoing PCIs with stable CAD are not receiving optimal medical therapy, 12 it is likely that at least 150 000 more PCI cases are inappropriate and cost savings are closer to $6 billion annually.The work of these authors shows a promising method of reducing unnecessary PCI by combining robust, unambiguous consensus guidelines with enforcement of accurate reporting of indications for PCI.However, these measures are not a cure-all in a health care system propelled by enthusiasm for technology regardless of net benefits and rewarded with fee-for-service payments not associated with the appropriateness of the procedure.

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