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Multicenter Study
. 2011 Jul 6;306(1):53-61.
doi: 10.1001/jama.2011.916.

Appropriateness of percutaneous coronary intervention

Paul S Chan  1 , Manesh R Patel, Lloyd W Klein, Ronald J Krone, Gregory J Dehmer, Kevin Kennedy, Brahmajee K Nallamothu, W Douglas Weaver, Frederick A Masoudi, John S Rumsfeld, Ralph G Brindis, John A Spertus
Affiliations
Multicenter Study

Appropriateness of percutaneous coronary intervention

Paul S Chan et al. JAMA. .

Abstract

Context: Despite the widespread use of percutaneous coronary intervention (PCI), the appropriateness of these procedures in contemporary practice is unknown.

Objective: To assess the appropriateness of PCI in the United States.

Design, setting, and patients: Multicenter, prospective study of patients within the National Cardiovascular Data Registry undergoing PCI between July 1, 2009, and September 30, 2010, at 1091 US hospitals. The appropriateness of PCI was adjudicated using the appropriate use criteria for coronary revascularization. Results were stratified by whether the procedure was performed for an acute (ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, or unstable angina with high-risk features) or nonacute indication.

Main outcome measures: Proportion of acute and nonacute PCIs classified as appropriate, uncertain, or inappropriate; extent of hospital-level variation in inappropriate procedures.

Results: Of 500,154 PCIs, 355,417 (71.1%) were for acute indications (ST-segment elevation myocardial infarction, 103,245 [20.6%]; non-ST-segment elevation myocardial infarction, 105,708 [21.1%]; high-risk unstable angina, 146,464 [29.3%]), and 144,737 (28.9%) for nonacute indications. For acute indications, 350,469 PCIs (98.6%) were classified as appropriate, 1055 (0.3%) as uncertain, and 3893 (1.1%) as inappropriate. For nonacute indications, 72,911 PCIs (50.4%) were classified as appropriate, 54,988 (38.0%) as uncertain, and 16,838 (11.6%) as inappropriate. The majority of inappropriate PCIs for nonacute indications were performed in patients with no angina (53.8%), low-risk ischemia on noninvasive stress testing (71.6%), or suboptimal (≤1 medication) antianginal therapy (95.8%). Furthermore, although variation in the proportion of inappropriate PCI across hospitals was minimal for acute procedures, there was substantial hospital variation for nonacute procedures (median hospital rate for inappropriate PCI, 10.8%; interquartile range, 6.0%-16.7%).

Conclusions: In this large contemporary US cohort, nearly all acute PCIs were classified as appropriate. For nonacute indications, however, 12% were classified as inappropriate, with substantial variation across hospitals.

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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Chan reported receiving support from a Career Development Grant Award (K23HL102224) from the National Heart, Lung, and Blood Institute (NHLBI) to examine the appropriateness of percutaneous coronary intervention in the United States. Dr Spertus reported having a contract from the American College of Cardiology (ACC) to analyze National Cardiovascular Data Registry (NCDR) data. Drs Brindis, Masoudi, and Rumsfeld reported receiving salary support from the ACC. No other authors reported disclosures.

Figures

Figure 1
Figure 1
PCI Appropriateness Study Cohort CT indicates computed tomography; NCDR, National Cardiovascular Data Registry; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction. aIncluded as part of sensitivity analyses.
Figure 2
Figure 2
Variation in Hospital Rates of Inappropriate Percutaneous Coronary Interventions for Nonacute Indications A, Distribution of hospital rates of inappropriate percutaneous coronary interventions (PCIs) for non-acute indications. Only hospitals with at least 10 non-acute PCIs annually were included (499 676 PCIs, 978 sites); 478 PCIs from 113 low-volume hospitals were excluded. The distribution of hospital rates was similar when analyses were restricted to hospitals with a minimum of 200 nonacute PCIs annually (see “Methods”). B, Relationship between a hospital’s nonacute PCI volume and its rate of inappropriate PCI in the nonacute setting.
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