Significant Decrease in Rates of Non-Acute Percutaneous Coronary Intervention since Release of Appropriate Use Criteria
BACKGROUND:
In 2009, the American College of Cardiology, the American Heart Association, and other professional societies released the Appropriate Use Criteria for Coronary Revascularization to critically examine and improve patient selection for percutaneous coronary intervention (PCI), as well as address concerns about potential overuse. However, there has been no comprehensive, national examination of trends in the indications, patient characteristics, and appropriateness of PCI procedures following the introduction of the Appropriate Use Criteria. Moreover, the extent of hospital-level variation in the proportion of non-acute PCI considered inappropriate has not been systematically examined over time. Therefore, this study sought to examine the trends in PCI utilization, patient selection, and procedural appropriateness following the introduction of Appropriate Use Criteria. The study cohort included all PCIs in the National Cardiovascular Data Registry (NCDR) – the largest national registry of diagnostic cardiac catheterization and PCI – from July 2009 through December 2014. After applying exclusion criteria, the study cohort included 2,685,683 PCI procedures from 766 hospitals.
FINDINGS:
- Since the publication of the Appropriate Use Criteria in 2009, there have been significant reductions in non-acute PCI volume. Among patients undergoing PCI between July 2009 and December 2014, the volumes of non-acute PCIs declined significantly – from 89,704 in 2010 to 59,375 in 2014, while the volume of acute PCIs remained stable – 377,540 in 2010 to 374,543 in 2014.
- There also were significant reductions in the proportion of non-acute PCIs classified as being inappropriate – from 26% in 2009 to 13% in 2014. However, there was persistent hospital-level variation in the rate of inappropriate PCIs, ranging from 6% to 23% in 2014.
- Among patients undergoing non-acute PCI, there were significant increases in angina severity (16% in 2010 vs. 38% in 2014); use of anti-anginal medications prior to PCI (at least two anti-anginal medications, 22% in 2010 vs. 35% in 2014); and high-risk findings on non-invasive testing (22% in 2010 vs. 33% in 2014), suggesting improvements in patient selection and clinical decision-making.
IMPLICATIONS:
- The volume of non-acute PCI and the proportion of non-acute PCIs classified as inappropriate has declined, though hospital-level variation in inappropriate PCI persists, suggesting the need for ongoing QI initiatives.
LIMITATIONS:
- Not all hospitals that perform PCI in the U.S. participate in the NCDR registry.
- This analysis focused mostly on trends in potential overuse (i.e., inappropriate) PCI. Understanding whether Appropriate Use Criteria have introduced new barriers to the performance of medically necessary procedures remains an important topic that cound not be addressed in this study.
AUTHOR/FUNDING INFORMATION:
Dr. Bradley is supported by an HSR&D Career Development Award and is part of HSR&D's Center for Innovation for Veteran-Centered and Value-Driven Care located in Seattle, WA and Denver, CO.
Desai N, Bradley S, Parzynski C, et al. Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection, and Appropriateness of Percutaneous Coronary Intervention. JAMA. November 17, 2015;314(19):2045-53.
