Rates of both nonacute and inappropriate PCI dropped substantially in response to a concerted nationwide effort to curb overuse of the procedure, including the introduction of appropriate use criteria, Dr. Nihar R. Desai said in a presentation at the American Heart Association scientific sessions, which was simultaneously published online Nov. 9 in JAMA.
The American College of Cardiology and the American Heart Association, in conjunction with other professional societies, released appropriate use criteria for coronary revascularization in 2009 and revised them in 2011. Research indicated that the risks of the procedure outweighed the benefits in as many as 17% of patients, and that the proportion of inappropriate PCIs varied markedly across hospitals.
In what he described as the first comprehensive assessment of PCI appropriateness since that time, Dr. Desai and his associates examined national trends using information from the National Cardiovascular Data Registry’s CathPCI registry.
They focused on 2,685,683 PCIs performed at 766 U.S. hospitals during a 5-year period. A total of 76.3% of these were done for acute indications, and 14.8% were for nonacute indications. The indications could not be determined for the remaining 8.9%, usually because data were missing from the records, said Dr. Desai of the center for outcomes research and evaluation, Yale–New Haven (Conn.) Hospital (JAMA 2015 Nov 9. doi: 10.1001/jama.2015.13764).
Over time, substantial declines occurred in the number of nonacute PCIs (from 89,704 in 2010 to 59,375 in 2014) and of indeterminate PCIs (from 70,832 in 2010 to 22,589 in 2014), while the number of acute PCIs remained relatively stable (from 377,540 in 2010 to 374,543 in 2014). As a result, the percentage of PCIs performed for acute indications rose from 69.1% in 2009 to 82.0% in 2014.
Similarly, the number of nonacute PCIs classified as inappropriate dropped from 21,781 in 2010 to 7,921 in 2014. Accordingly, the percentage of nonacute PCIs deemed to be inappropriate was halved, decreasing from 26.2% in 2009 to 13.3% in 2014 of all nonacute PCIs.
The results reflect improvement in patient selection and clinical decision making, Dr. Desai said, and suggest that clinicians are doing a better job of identifying patients most likely to benefit from PCI.
In particular, “we observed significant declines in the proportions of patients undergoing nonacute PCI who were asymptomatic or had minimal symptoms, who were not receiving or were receiving only minimal antianginal therapy, and who had low- or intermediate-risk findings on noninvasive testing,” he noted.
“Collectively, these findings suggest that the practice of interventional cardiology has evolved since the introduction of appropriate use criteria,” Dr. Desai added.
The wide variation in inappropriate PCI across hospitals remains, however.
In the best-performing hospitals (those in the lowest quartile for inappropriate procedures), less than 6% of nonacute PCIs were classified as inappropriate in 2014, the most recent year for which data are available.
Conversely, in the worst-performing hospitals (those in the highest quartile for inappropriate procedures), more than 22% of nonacute PCIs were deemed inappropriate. This “suggests the need for ongoing performance improvement initiatives and hospital benchmarking,” Dr. Desai noted
It was encouraging that many of the worst-performing hospitals at baseline demonstrated immediate and steady improvement after the introduction of appropriate use criteria, he added, with a dramatic reduction in inappropriate PCIs from 70.6% in 2009-2010 to 9.4% in 2014.
However, a subset of 18 of the worst-performing hospitals showed minimal change during the first 2 years of the study. They have subsequently shown lower rates of inappropriate PCI during the final 2 years.
This study was supported by the National Cardiovascular Data Registry’s CathPCI registry, the Yale Center for Outcomes Research and Evaluation Data Analytic Center, the American College of Cardiology, the Agency for Healthcare Research and Quality, Veterans Affairs Health Services Research and Development, and the National Heart, Lung, and Blood Institute. Dr. Desai reported ties to Johnson & Johnson, and his associates reported ties to several industry sources.