Author Affiliations: Department of Internal Medicine, Saint Luke's Mid America Heart Institute, Kansas City, Missouri (firstname.lastname@example.org).
In Reply: Dr Restuccia and colleagues are correct in noting that threats to the quality of PCI include underuse, overuse (which we examined), and misuse (performing the procedure poorly1 in those who appropriately receive it). We believe that underuse is an important problem that warrants further research. Hemingway et al2 have suggested that failure to perform revascularization in appropriate patients can be associated with poorer outcomes. Further insight into underuse, however, will require a different methodology than what has been applied in prior studies.
Chan PS, Spertus JA. Underuse of Percutaneous Coronary Intervention—Reply. JAMA. 2011;306(19):2094-2095. doi:10.1001/jama.2011.1659