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IMPORTANCE Guidelines endorse routine coronary angiography and percutaneous coronary intervention (PCI) to screen for and treat cardiac allograft vasculopathy in heart transplant recipients. However, the current Appropriate Use Criteria for Revascularization (AUC-R) do not recognize prior heart transplant as a unique PCI indication. Whether this affects rates of rarely appropriate (RA) PCIs is unknown.OBJECTIVE To assess the rate of RA PCI procedures in heart transplant recipients and how it pertains to hospital PCI appropriateness metrics and pay-for-performance scorecards. DESIGN, SETTING, AND PARTICIPANTS This observational study used National Cardiovascular Data Registry CathPCI Registry data on all patients undergoing elective PCIs from 96 Medicare-approved heart transplant centers from quarter 3 of 2009 to quarter 2 of 2017. The data were analyzed in July 2018. EXPOSURES Prior heart transplant. MAIN OUTCOMES AND MEASURESRates of RA elective PCIs in heart transplant recipients compared with nonrecipients and hospital rates of RA PCI before vs after exclusion of heart transplant recipients using paired t tests. In a subset of heart transplant centers participating in the Anthem Blue Cross and Blue Shield's Quality-In-Sights Hospital Incentive Program (Q-HIP), we compared the change in Q-HIP scorecards before vs after excluding heart transplant recipients. RESULTSOf 168 802 participants, 123 124 (72.9%) were men, 137 457 were white, and the mean (SD) age was 66.3 (11.4) years. Of 168 802 elective PCIs performed in heart transplant centers, 1854 (1.1%) were for heart transplant recipients. Heart transplant recipients were less likely to have ischemic symptoms (14.6% vs 61.4%, P < .001), had lower rates of antecedent stress testing (15.0% vs 58.4%, P < .001), and had higher RA PCI rates (66.0% vs 16.9%, P < .001) compared with nonrecipients. In heart transplant centers, the absolute difference in RA rates (before vs after excluding transplant recipients) was directly associated with the proportion of PCIs performed in heart transplant recipients (r= 0.91; P < .001). In the subset of heart transplant centers participating in Q-HIP during the 2016 and 2017 calendar years, 8 of 20 (40%) and 8 of 16 centers (50%), respectively, could have benefited from a change in their Q-HIP scorecards if their RA PCI rates excluded transplant recipients.CONCLUSIONS AND RELEVANCE Two-thirds of PCIs in heart transplant recipients were deemed RA by the AUC-R. The failure of the AUC-R to consider prior heart transplant as a unique PCI indication may lead to inflated RA PCI rates with the potential for affecting quality reporting and pay-for-performance metrics in heart transplant centers.
IMPORTANCE Guidelines endorse routine coronary angiography and percutaneous coronary intervention (PCI) to screen for and treat cardiac allograft vasculopathy in heart transplant recipients. However, the current Appropriate Use Criteria for Revascularization (AUC-R) do not recognize prior heart transplant as a unique PCI indication. Whether this affects rates of rarely appropriate (RA) PCIs is unknown.OBJECTIVE To assess the rate of RA PCI procedures in heart transplant recipients and how it pertains to hospital PCI appropriateness metrics and pay-for-performance scorecards. DESIGN, SETTING, AND PARTICIPANTS This observational study used National Cardiovascular Data Registry CathPCI Registry data on all patients undergoing elective PCIs from 96 Medicare-approved heart transplant centers from quarter 3 of 2009 to quarter 2 of 2017. The data were analyzed in July 2018. EXPOSURES Prior heart transplant. MAIN OUTCOMES AND MEASURESRates of RA elective PCIs in heart transplant recipients compared with nonrecipients and hospital rates of RA PCI before vs after exclusion of heart transplant recipients using paired t tests. In a subset of heart transplant centers participating in the Anthem Blue Cross and Blue Shield's Quality-In-Sights Hospital Incentive Program (Q-HIP), we compared the change in Q-HIP scorecards before vs after excluding heart transplant recipients. RESULTSOf 168 802 participants, 123 124 (72.9%) were men, 137 457 were white, and the mean (SD) age was 66.3 (11.4) years. Of 168 802 elective PCIs performed in heart transplant centers, 1854 (1.1%) were for heart transplant recipients. Heart transplant recipients were less likely to have ischemic symptoms (14.6% vs 61.4%, P < .001), had lower rates of antecedent stress testing (15.0% vs 58.4%, P < .001), and had higher RA PCI rates (66.0% vs 16.9%, P < .001) compared with nonrecipients. In heart transplant centers, the absolute difference in RA rates (before vs after excluding transplant recipients) was directly associated with the proportion of PCIs performed in heart transplant recipients (r= 0.91; P < .001). In the subset of heart transplant centers participating in Q-HIP during the 2016 and 2017 calendar years, 8 of 20 (40%) and 8 of 16 centers (50%), respectively, could have benefited from a change in their Q-HIP scorecards if their RA PCI rates excluded transplant recipients.CONCLUSIONS AND RELEVANCE Two-thirds of PCIs in heart transplant recipients were deemed RA by the AUC-R. The failure of the AUC-R to consider prior heart transplant as a unique PCI indication may lead to inflated RA PCI rates with the potential for affecting quality reporting and pay-for-performance metrics in heart transplant centers.
See article by Miller et al., pages 1236e1243 of this issue.Clinical practice guidelines recommend coronary artery bypass surgery (CABG) as the optimal revascularization strategy in patients with diabetes and multivessel coronary disease. [1][2][3] Although many trials have studied this issue, the Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) was the first adequately powered trial to compare CABG vs percutaneous coronary intervention (PCI) with drug-eluting stents in patients with diabetes, in addition to optimal medical therapy. 4 A total of 1900 patients were randomized and, after a median follow-up of 3.8 years, CABG, compared with PCI, reduced the composite of allcause mortality, nonfatal myocardial infarction, and stroke (18.7% vs 26.6%; P ¼ 0.005). 4 A long-term follow-up of this trial (median of 7.5 years) showed that PCI was associated with excess mortality, with a hazard ratio of 1.36 (95% confidence interval [CI], 1.07-1.74; P ¼ 0.01). 5 A pooled analysis of patient-level data from 11 clinical trials, including 3266 patients with diabetes and multivessel disease, also corroborated these findings. 6 The results of the FREEDOM trial were first presented at the American Heart Association Congress on November 4, 2012 and simultaneously published online. 4 The FREEDOM results were gradually incorporated into clinical practice guidelines internationally. [1][2][3] The ultimate goal of clinical research is to inform clinical practice, providing better care to our patients. This process usually begins at the bedside, by recognizing a knowledge gap, which will lead to a clinically relevant research question to be pursued in a trial. The cycle is completed when the scientific evidence generated by the trial is incorporated into guidelines and ultimately into clinical practice, benefiting patients. Although
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