Temporal Trends in Percutaneous Coronary Intervention Appropriateness

Bradley, Steven M; Bohn, Chad M.; Malenka, David J.; Graham, Michelle M.; Bryson, Chris L.; McCabe, James M.; Curtis, Jeptha P.; Lambert-Kerzner, Anne; Maynard, Charles

doi:10.1161/circulationaha.114.015156

Cited by 60 publications

(22 citation statements)

References 17 publications

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“…3,7 Our findings are consistent with an analysis of PCI appropriateness in Washington State. 21 However, because the registry was not configured to characterize PCI appropriateness until July 2009, our analyses are limited to cases performed after the release of the Appropriate Use Criteria. As such we could not evaluate the impact of the Appropriate Use Criteria, and our findings are best considered a description of changes in patterns of care and procedural appropriateness over this period.…”

Section: Discussionmentioning

confidence: 99%

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

Desai

Bradley

Parzynski

et al. 2015

JAMA

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217

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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, Participants Multi-center, longitudinal, cross-sectional analysis of patients undergoing PCI between July 1, 2009 and December 31, 2014 at hospitals continuously participating in NCDR-CathPCI Registry over the study period. Main Outcome Measures Proportion of non-acute 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 for acute indications was consistent over the study period (2010: 377,540; 2014: 374,543), but the volume for non-acute PCIs decreased from 89,704 in 2010 to 59,375 in 2014. Among patients undergoing non-acute PCI, there were significant increases in angina severity (CCS III/IV angina, 15.8% and 38.4% in 2010 and 2014 respectively), use of anti-anginal medications prior to PCI (at least 2 anti-anginal medication, 22.3% and 35.1% in 2010 and 2014 respectively), and high-risk findings on non-invasive testing (22.2% and 33.2% in 2010 and 2014 respectively) (p<0.001 for all), but only modest increases in multivessel CAD (43.7% and 47.5% in 2010 and 2014 respectively, p<0.001). The proportion (95% CI) of non-acute 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 7,921. Hospital-level variation in the proportion of PCIs classified as inappropriate was persistent over the study period (median 12.6%, IQR 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 non-acute PCI volume. The proportion of non-acute PCIs classified as inappropriate has declined though hospital-level variation in inappropriate PCI persists.

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Section: Discussionmentioning

confidence: 99%

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

Desai

Bradley

Parzynski

et al. 2015

JAMA

Self Cite

217

132

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“…The article by Bradley and colleagues 6 in this issue of Circulation provides some insight into that question. Using data from the Washington State Clinical Outcomes Assessment Program, they examined temporal trends in the number of percutaneous coronary intervention (PCI) procedures performed, specifically the number of PCIs rated as inappropriate.…”

Section: Article See P 20mentioning

confidence: 99%

Use of Appropriate Use Criteria Is Increasing, but What Are Their Effects on Medical Care?

Dehmer

Patel

2015

Circulation

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Editorial 4T he first appropriate use criteria (AUC) for coronary revascularization were published in 2009 with an update published in 2012.1,2 A new version of the AUC for coronary revascularization is currently under development and will, we hope, address some of the constructive criticisms directed at the earlier versions. The use of AUC is increasing, and several other organizations have developed AUC for different procedures outside the cardiovascular arena. For example, orthopedic surgeons now have AUC for several of their common procedures, the American Academy of Dermatology has AUC for Mohs surgery, and AUC for the placement of Foley catheters recently were published. [3][4][5] With the increasing development, promotion, and adoption of AUC, it is reasonable to ask a critical question: What are the effects of AUC on the delivery of cardiovascular care? This is a fair question because the AUC are intended to address the rational use of coronary revascularization, to provide a practical standard on which to assess and understand variability, and to evaluate overall patterns of care for coronary revascularization. Article see p 20The article by Bradley and colleagues 6 in this issue of Circulation provides some insight into that question. Using data from the Washington State Clinical Outcomes Assessment Program, they examined temporal trends in the number of percutaneous coronary intervention (PCI) procedures performed, specifically the number of PCIs rated as inappropriate. High-performing hospitals were identified by a low or declining proportion of inappropriate PCIs or PCIs performed with insufficient preprocedural information to allow the assessment of appropriateness. They showed that, after the adoption of the Clinical Outcomes Assessment Program, there was an overall decline in the number of PCIs performed and specifically a substantial decline in the number of PCIs for elective indications. Although there was a slight increase in the number of PCIs performed for unstable angina or non-STsegment-elevation myocardial infarction during the same period, this increase was insufficient to explain the decline in elective PCIs. Therefore, the increase in PCIs for acute coronary syndromes was not felt to be the result of operators simply learning the coding system and shifting the diagnosis. The decline in the use of elective PCI was significantly larger after the onset of the statewide PCI appropriateness assessment, with a modest increase in the proportion of elective PCIs classified as appropriate and a modest decrease in the proportion of inappropriate PCIs. Of note, the decline in the proportion of inappropriate PCI was limited to the tertile of hospitals with the largest decline in PCIs classified as inappropriate (25% in 2010 to 12% in 2013). This observation must be viewed within the context that the number of PCIs in the United States has also declined in the same time period. Whether this is related to the overall adoption of the AUC for revascularization, AUC for diagnostic cardiac catheterizati...

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“…With regard to some hospitals showing trends that were contrary to general trends, Bradley et al assessed the appropriateness of PCIs performed in Washington State and noted that hospitals in the tertile with the least improvement in the proportion of inappropriate PCIs had a temporal increase in the proportion of inappropriate PCIs from 12% in 2010 to 20% in 2013 [9]. The authors suggested that additional qualitative studies on hospitals with increasing proportions of inappropriate PCIs may serve to validate the patient selection processes.…”

Section: Discussionmentioning

confidence: 99%

“…However, only few studies have further examined the regional and hospital variations in the percentage of PCIs for nonacute indications [5, 9, 10]. …”

Section: Introductionmentioning

confidence: 99%

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Regional and hospital variations in the extent of decline in the proportion of percutaneous coronary interventions performed for nonacute indications – a nationwide population-based study

Liang

et al. 2017

BMC Cardiovasc Disord

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BackgroundThe volume and percentage of percutaneous coronary interventions (PCIs) performed for nonacute indications have declined in the United States since 2007. However, little is known if similar trends occurred in Taiwan.MethodsWe used data from Taiwan National Health Insurance inpatient claims to examine the regional and hospital variations in the extent of decline in the percentage of nonacute indication PCIs from 2007 to 2012.ResultsThe volume of total PCIs persistently increased from 29,032 in 2007 to 35,811 in 2010 and 37,426 in 2012. However, the volume of nonacute indication PCIs first increased from 7916 in 2007 to 9143 in 2009 and then decreased to 8666 in 2012. The percentage of nonacute indication PCIs steadily decreased from 27% in 2007 to 26% in 2009 and then to 23% in 2012, a − 15% change. The extent of decline was largest in the North region (from 27% to 21%, a − 22% change) and least in Kaopin region (from 20% to 18%, a − 13% change). Of the 71 hospitals studied, 14 did not show a decreasing trend. Five of the 14 hospitals even showed an increasing trend, with a percentage change >10% between 2007 and 2012. In 2012, 6 hospitals had a nonacute indication PCI percentage >35%.ConclusionsIn Taiwan, four-fifths of the hospitals showed a decline in the percentage of nonacute indication PCIs from 2007 to 2012. It is plausible that Taiwanese cardiologists would have been influenced by the recommendations of crucial US trials and guidelines.

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Temporal Trends in Percutaneous Coronary Intervention Appropriateness

Abstract: Background-It is unknown whether the appropriate use of percutaneous coronary intervention (PCI) has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the use of PCI. Methods and Results-We

Cited by 60 publications

References 17 publications

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

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

Use of Appropriate Use Criteria Is Increasing, but What Are Their Effects on Medical Care?

Regional and hospital variations in the extent of decline in the proportion of percutaneous coronary interventions performed for nonacute indications – a nationwide population-based study

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