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Multicenter Study
. 2015 Nov 17;314(19):2045-53.
doi: 10.1001/jama.2015.13764.

Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection, and Appropriateness of Percutaneous Coronary Intervention

Nihar R Desai  1 , Steven M Bradley  2 , Craig S Parzynski  3 , Brahmajee K Nallamothu  4 , Paul S Chan  5 , John A Spertus  5 , Manesh R Patel  6 , Jeremy Ader  7 , Aaron Soufer  8 , Harlan M Krumholz  1 , Jeptha P Curtis  1
Affiliations
Multicenter Study

Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection, and Appropriateness of Percutaneous Coronary Intervention

Nihar R Desai et al. JAMA. .

Abstract

Importance: Appropriate Use Criteria for Coronary Revascularization were developed to critically evaluate and improve patient selection for percutaneous coronary intervention (PCI). National trends in the appropriateness of PCI have not been examined.

Objective: To examine trends in PCI utilization, patient selection, and procedural appropriateness following the introduction of Appropriate Use Criteria.

Design, setting, and participants: Multicenter, longitudinal, cross-sectional analysis of patients undergoing PCI between July 1, 2009, and December 31, 2014, at hospitals continuously participating in the National Cardiovascular Data Registry CathPCI registry over the study period.

Main outcomes and measures: Proportion of nonacute PCIs classified as inappropriate at the patient and hospital level using the 2012 Appropriate Use Criteria for Coronary Revascularization.

Results: A total of 2.7 million PCI procedures from 766 hospitals were included. Annual PCI volume of acute indications was consistent over the study period (377,540 in 2010; 374,543 in 2014), but the volume of nonacute PCIs decreased from 89,704 in 2010 to 59,375 in 2014. Among patients undergoing nonacute PCI, there were 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 prior to PCI (at least 2 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 < .001 for all), but only modest increases in multivessel coronary artery disease (43.7% in 2010 and 47.5% in 2014, P < .001). The proportion of nonacute PCIs classified as inappropriate decreased from 26.2% (95% CI, 25.8%-26.6%) to 13.3% (95% CI, 13.1%-13.6%), and the absolute number of inappropriate PCIs decreased from 21,781 to 7921. Hospital-level variation in the proportion of PCIs classified as inappropriate persisted over the study period (median, 12.6% [interquartile range, 5.9%-22.9%] in 2014).

Conclusions and relevance: Since the publication of the Appropriate Use Criteria for Coronary Revascularization in 2009, there have been significant reductions in the volume of nonacute PCI. The proportion of nonacute PCIs classified as inappropriate has declined, although hospital-level variation in inappropriate PCI persists.

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Conflict of interest statement

Conflicts of Interest

Drs. Desai and Krumholz are recipients of a research agreement from Johnson & Johnson, through Yale University, to develop methods of clinical trial data sharing. Drs. Desai, Krumholz and Curtis receive funding from the Centers for Medicare & Medicaid Services to develop and maintain performance measures that are used for public reporting. Dr. Krumholz receives research support from Medtronic, through Yale University, to develop methods of clinical trial data sharing and of a grant from the Food and Drug Administration to develop methods for post-market surveillance of medical devices. Dr. Krumholz chairs a cardiac scientific advisory board for UnitedHealth. Dr. Spertus discloses funding from the American College of Cardiology to analyze the NCDR registries, membership on the United Healthcare cardiac scientific advisory board and an equity interest in Health Outcomes Sciences. Dr. Patel has research grants through Duke University with Johnson and Johnson, AstraZeneca, Maquet, National Heart Lung and Blood Institute, AHRQ, and is on the Advisory Board for Bayer Healthcare, Jansen, and Genzyme. Dr. Curtis discloses equity interest in Medtronic. No other disclosures were reported.

Figures

Figure 1
Figure 1. Proportion of PCI Performed for Acute, Non-acute, and Non-mappable Indications at the Hospital-level from 2009 to 2014
Hospital-level proportion of acute, non-acute, and non-mappable indications for all PCIs performed from July 1, 2009 to December 31, 2014 at 766 hospitals participating continuously in the NCDR-CathPCI Registry over the study period. For each box-plot, the vertical line in the center of the rectangle represents the median, the left and right vertical lines of each rectangle represent the 25th and 75th percentiles respectively, and the vertical lines capping the horizontal lines extending from the rectangle represent 1.5-times the interquartile range. Each hospital is represented as a point in the box-plot, the size of the point reflects the hospital volume. Note: Results for 2009 include 6-months of data.
Figure 1
Figure 1. Proportion of PCI Performed for Acute, Non-acute, and Non-mappable Indications at the Hospital-level from 2009 to 2014
Hospital-level proportion of acute, non-acute, and non-mappable indications for all PCIs performed from July 1, 2009 to December 31, 2014 at 766 hospitals participating continuously in the NCDR-CathPCI Registry over the study period. For each box-plot, the vertical line in the center of the rectangle represents the median, the left and right vertical lines of each rectangle represent the 25th and 75th percentiles respectively, and the vertical lines capping the horizontal lines extending from the rectangle represent 1.5-times the interquartile range. Each hospital is represented as a point in the box-plot, the size of the point reflects the hospital volume. Note: Results for 2009 include 6-months of data.
Figure 1
Figure 1. Proportion of PCI Performed for Acute, Non-acute, and Non-mappable Indications at the Hospital-level from 2009 to 2014
Hospital-level proportion of acute, non-acute, and non-mappable indications for all PCIs performed from July 1, 2009 to December 31, 2014 at 766 hospitals participating continuously in the NCDR-CathPCI Registry over the study period. For each box-plot, the vertical line in the center of the rectangle represents the median, the left and right vertical lines of each rectangle represent the 25th and 75th percentiles respectively, and the vertical lines capping the horizontal lines extending from the rectangle represent 1.5-times the interquartile range. Each hospital is represented as a point in the box-plot, the size of the point reflects the hospital volume. Note: Results for 2009 include 6-months of data.
Figure 2
Figure 2. Proportions of Appropriate, Inappropriate, and Uncertain PCI at the Patient-level (A) and Proportions of Inappropriate PCI at the Hospital-level (B) among Non-acute PCIs from July 1, 2009 to December 31, 2014
Figure 2A/B. Rates of Appropriate, Inappropriate, and Uncertain PCI at the Patient-level (A) and Rate of Inappropriate PCI at the Hospital-level (B) among non-acute PCIs from July 1, 2009 to December 31, 2014 at 766 hospitals participating continuously in the NCDR-CathPCI Registry over the study period. For each classification of procedural appropriateness, the point estimate and 95% CI are plotted in Figure 2A. For each box-plot in Figure 2B, the horizontal line in the center of the rectangle represents the median, the bottom and top horizontal lines of each rectangle represent the 25th and 75th percentiles respectively, and the horizontal lines capping the vertical lines extending from the rectangle represent 1.5-times the interquartile range. Each hospital is represented as a point in the box-plot, the size of the point reflects the hospital volume. Note: Results from 2009 include 6-months of data.
Figure 2
Figure 2. Proportions of Appropriate, Inappropriate, and Uncertain PCI at the Patient-level (A) and Proportions of Inappropriate PCI at the Hospital-level (B) among Non-acute PCIs from July 1, 2009 to December 31, 2014
Figure 2A/B. Rates of Appropriate, Inappropriate, and Uncertain PCI at the Patient-level (A) and Rate of Inappropriate PCI at the Hospital-level (B) among non-acute PCIs from July 1, 2009 to December 31, 2014 at 766 hospitals participating continuously in the NCDR-CathPCI Registry over the study period. For each classification of procedural appropriateness, the point estimate and 95% CI are plotted in Figure 2A. For each box-plot in Figure 2B, the horizontal line in the center of the rectangle represents the median, the bottom and top horizontal lines of each rectangle represent the 25th and 75th percentiles respectively, and the horizontal lines capping the vertical lines extending from the rectangle represent 1.5-times the interquartile range. Each hospital is represented as a point in the box-plot, the size of the point reflects the hospital volume. Note: Results from 2009 include 6-months of data.
Figure 3
Figure 3. Trends in Inappropriate Non-Acute PCI at Hospitals with the Highest Initial Proportion of Inappropriate PCI (>34% from July 2009 to December 2010)
Observed Rates (95% CI) of Inappropriate non-acute PCI for 4 groups of hospitals identified by latent growth curve analysis. The analysis was restricted to hospitals with the highest initial rates of inappropriate non-acute PCI from July 2009 to December 2010 (>34%, n=191). Note: Results shown for 2010 include data for 2009 and 2010.
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References

    1. Patel MR, Dehmer GJ, Hirshfeld JW, et al. 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 Feb 10;53(6):530–553. - PubMed
    1. [Accessed June 15, 2015];Proceedings from the National Summit on Overuse. http://www.jointcommission.org/assets/1/6/National_Summit_Overuse.pdf.
    1. Chan PS, Patel MR, Klein LW, et al. Appropriateness of percutaneous coronary intervention. Jama. 2011 Jul 6;306(1):53–61. - PMC - PubMed
    1. Bradley SM, Maynard C, Bryson CL. Appropriateness of percutaneous coronary interventions in Washington State. Circulation. Cardiovascular quality and outcomes. 2012 Jul 1;5(4):445–453. - PubMed
    1. [Accessed July 2, 2015];Heart Treatment Overused. http://www.wsj.com/articles/SB10001424052702304760604576428323005864648.

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