Veronica Hackethal, MD

November 10, 2015

ORLANDO, FL — The proportion of inappropriate PCIs has decreased since the publication of the appropriate-use criteria for coronary revascularization in 2009, according to a new study published online November 9, 2015 in the Journal of the American Medical Association to coincide with presentation at the American Heart Association (AHA) 2015 Scientific Sessions[1].

"Over a very short period of time, we have seen dramatic reductions in inappropriate PCI, suggesting that the appropriate-use criteria have helped improve patient selection for PCI and have had a significant impact on the practice of interventional cardiology," commented first author Dr Nihar Desai (Yale School of Medicine, New Haven, CT) to heartwire from Medscape.

Dr Nihar Desai

Over the 5-year period studied, the volume of PCIs for nonacute or elective reasons decreased by 34%, while there was a "highly significant" 50% relative reduction in the proportion of inappropriate PCIs, he added

"This is a testament to professionalism," Dr Desai emphasized. "Cardiologists deserve a lot of credit for having faced a difficult issue and for making dramatic improvement in clinical care for patients within 5 years."

Appropriate-Use Criteria for Coronary Revascularization

The appropriate-use criteria for coronary revascularization were released in 2009 by the American College of Cardiology (ACC), the AHA, and other allied professional organizations, with the goal of improving patient selection for PCI. In 2012, the criteria were further refined for nonacute indications. An "appropriate" rating means that the benefits of the procedure probably outweigh the risks.

Past studies have suggested that about one in six nonacute PCIs can be considered inappropriate and that hospitals vary widely in the number of inappropriate PCIs they perform.

This latest study is the first to look at national trends in PCI after the publication of the appropriate-use criteria, as well as the first to look at hospital variation in inappropriate nonacute PCI.

It included hospitals that participated continuously from July 2009 to December 2014 in the National Cardiovascular Data Registry (known as CathPCI). The CathPCI includes data on diagnostic cardiac catheterization and PCI from over 1500 institutions across the US. Researchers used the 2012 appropriate-use criteria to identify the proportion of nonacute PCIs that could be considered inappropriate.

Significant Hospital Level Variation

The analysis included 2.7 million PCIs completed at 766 hospitals. While the annual number of acute PCIs stayed virtually the same over the study period (377,540 in 2010 compared with 374, 543 in 2014), a significant reduction occurred in the number of nonacute PCIs (89,704 in 2010 compared with 59,375 in 2014; P<0.001).

Patients who underwent nonacute PCIs showed significant increases in angina severity (Canadian Cardiovascular Society grade III/IV angina: 15.8% in 2010 and 38.4% in 2014), use of antianginal medications before PCI (at least two antianginal medications: 22.3% in 2010 and 35.1% in 2014), and high-risk findings on noninvasive testing (22.2% in 2010 and 33.2% in 2014) (P<0.001 for all).

On the other hand, these patients had only modest increases in multivessel coronary artery disease (43.7% in 2010 and 47.5% in 2014, P<0.001).

The proportion of inappropriate nonacute PCIs decreased from 26.2% in 2010 to 13.3% in 2014 (P<0.001), as did the absolute number of inappropriate PCIs (from 21,781 in 2010 to 7921 in 2014).

Hospital-level variation in the proportion of inappropriate PCIs stayed about the same during the study period, with a median of 12.6% in 2014.

In better-performing hospitals, less than 6% of nonacute PCIs were considered inappropriate, while 22% were considered inappropriate in the worst-performing hospitals.

"While inappropriate PCIs seem to be on the decline, there is significant hospital-level variation in performance, suggesting the need for ongoing quality improvement efforts," Desai stressed.

"In addition, there is still a problem of potential underuse of PCI and disparities in care, which are very important to study and target for improvement."

And it will be important to understand whether the appropriate-use criteria introduced any barriers to medically necessary procedures, he added.

ACC, AHA Play Big Role, but Still Room for Improvement

"These findings highlight the importance of efforts by professional cardiology organizations and US cardiologists," writes Dr Robert A Harrington (Stanford University, CA), in an accompanying editorial[2].

He notes also the role played by the ACC and AHA, investing in a national quality registry system and emphasizing quality improvement as a central focus.

"Equally critical to the positive progress being made, as noted by Desai and colleagues, is the response to appropriate-use criteria in PCI by US cardiologists and hospital systems," he continued, pointing out the positive emphasis on using the evidence base to guide care in the cardiology community.

But there is still more room for improvement. Hospitals that do advanced procedures like PCI should be required, Harrington proposes, to participate in the National Cardiovascular Data Registry. Interoperable medical records are also needed to allow for faster data sharing that can be used to create registry-based randomized clinical trials.

"What is needed is a national system that allows immediate real-time decision support for clinical activities fully integrated with clinical research capabilities that use constantly accumulating data and sophisticated data analytics, including randomization when appropriate," Harrington concludes.

"Only at that point will the continuously learning healthcare system be a reality."

Desai reports receiving a research agreement from Johnson & Johnson, through Yale University, to develop methods of clinical-trial data sharing and receiving funding from the Centers for Medicare & Medicaid Services to develop and maintain performance measures used for public reporting. Disclosures for the coauthors are listed in the article. Harrington reports being a member of the American College of Cardiology board of trustees from 2008 to 2015 and is currently a member of the American Heart Association board of directors.


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