Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2015 Sep 17;10(9):e0138251.
doi: 10.1371/journal.pone.0138251. eCollection 2015.

Percutaneous Coronary Intervention Utilization and Appropriateness across the United States

Michael P Thomas  1 , Craig S Parzynski  2 , Jeptha P Curtis  2 , Milan Seth  3 , Brahmajee K Nallamothu  1 , Paul S Chan  4 , John A Spertus  4 , Manesh R Patel  5 , Steven M Bradley  6 , Hitinder S Gurm  1
Affiliations

Percutaneous Coronary Intervention Utilization and Appropriateness across the United States

Michael P Thomas et al. PLoS One. .

Abstract

Background: Substantial geographic variation exists in percutaneous coronary intervention (PCI) use across the United States. It is unclear the extent to which high PCI utilization can be explained by PCI for inappropriate indications. The objective of this study was to examine the relationship between PCI rates across regional healthcare markets utilizing hospital referral regions (HRRs) and PCI appropriateness.

Methods: The number of PCI procedures in each HRR was obtained from the 2010 100% Medicare limited data set. HRRs were divided into quintiles of PCI utilization with increasing rates of utilization progressing to quintile 5. NCDR CathPCI Registry® data were used to evaluate patient characteristics, appropriate use criteria (AUC), and outcomes across the HRR quintiles defined by PCI utilization with the study population restricted to HRRs where ≥ 80% of the PCIs were performed at institutions participating in the registry. PCI appropriateness was defined using 2012 AUC by the American College of Cardiology (ACC)/American Heart Association (AHA)/The Society for Cardiovascular Angiography and Interventions (SCAI).

Results: Our study cohort comprised of 380,981 patients treated at 178 HRRs. Mean PCI rates per 1,000 increased from 4.6 in Quintile 1 to 10.8 in Quintile 5. The proportion of non-acute PCIs was 27.7% in Quintile 1 increasing to 30.7% in Quintile 5. Significant variation (p < 0.001) existed across the quintiles in the categorization of appropriateness across HRRs of utilization with more appropriate PCI in lower utilization areas (Appropriate: Q1, 76.53%, Q2, 75.326%, Q3, 75.23%, Q4, 73.95%, Q5, 72.768%; Inappropriate: Q1 3.92%, Q2 4.23%, Q3 4.32%, Q4 4.35%, Q5 4.05%; Uncertain: Q1 8.29%, Q2 8.84%, Q3 8.08%, Q4 9.01%, Q5 8.93%; Not Mappable: Q1 11.26%, Q2 11.67%, Q3 12.37%, Q4 12.69%, Q5 14.34%). There was no difference in risk-adjusted mortality across quintiles of PCI utilization.

Conclusions: Geographic regions with lower PCI rates have a higher proportion of PCIs performed for appropriate indications. Areas that perform more PCIs also appear to perform more elective PCI and many could not be mapped by the AUC.

PubMed Disclaimer

Conflict of interest statement

Competing Interests: Dr. Curtis receives salary support from the American College of Cardiology for data analytic services and has equity stock in Medtronic. Dr. Nallamothu serves on United Healthcare’s Scientific Cardiac Advisory Board. Dr. Gurm receives research support from the National Institutes of Health, Agency for Research Healthcare and Quality, and Blue Cross Blue Shield of Michigan. All other authors have no relationships relevant to the contents of this paper to disclose. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1. Final cohort available for primary analysis.
Shown is the final cohort for the primary analysis and the PCIs that were excluded.
Fig 2
Fig 2. Geographic distribution of HRRs categorized by quintiles of PCI utilization and included in analysis.
Shown are the HRRs divided by quintile of PCI utilization and the HRRs that were excluded from the analysis.
Fig 3
Fig 3. Distribution of PCI appropriateness across HRR quintiles for all PCIs.
Shown is the application of the appropriate use criteria to quintiles of PCI utilization for all PCIs.
Fig 4
Fig 4. Appropriateness use criteria classification of non- acute PCI across HRR quintiles of PCI utilization.
Shown is the application of appropriate use criteria to quintiles of PCI utilization for non-acute PCIs.
See this image and copyright information in PMC

References

    1. Matlock DD, Groeneveld PW, Sidney S, Shetterly S, Goodrich G, Glenn K, et al. Geographic variation in cardiovascular procedure use among Medicare fee-for-service vs Medicare Advantage beneficiaries. JAMA 2013;310:155–162. 10.1001/jama.2013.7837 - DOI - PMC - PubMed
    1. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Journal of the American College of Cardiology 2011;58:e44–122. 10.1016/j.jacc.2011.08.007 - DOI - PubMed
    1. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography. Journal of the American College of Cardiology 2009;53:530–553. 10.1016/j.jacc.2008.10.005 - DOI - PubMed
    1. Chan PS, Patel MR, Klein LW, Krone RJ, Dehmer GJ, Kennedy K, et al. Appropriateness of percutaneous coronary intervention. JAMA 2011;306:53–61. 10.1001/jama.2011.916 - DOI - PMC - PubMed
    1. Hannan EL, Cozzens K, Samadashvili Z, Walford G, Jacobs AK, Holmes DR, et al. Appropriateness of coronary revascularization for patients without acute coronary syndromes. Journal of the American College of Cardiology 2012;59:1870–1876. 10.1016/j.jacc.2012.01.050 - DOI - PubMed

MeSH terms

LinkOut - more resources