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Figure.
Proportion of Nonacute PCIs Classified as Rarely Appropriate
Proportion of Nonacute PCIs Classified as Rarely Appropriate

A, Hospital variation in the proportion of rarely appropriate PCIs stratified by review strategy. Each point represents the proportion of rarely appropriate PCIs performed at an individual hospital. The horizontal line represents the median of hospitals, and the bottom and top lines of the rectangle represent the 25th and 75th percentiles.

Table.  
Hospital Characteristics, Adjunctive Pharmacotherapy, and Clinical Outcomes Stratified by Appropriate Use Criteria Review Practices
Hospital Characteristics, Adjunctive Pharmacotherapy, and Clinical Outcomes Stratified by Appropriate Use Criteria Review Practices
1.
Chan  PS, Patel  MR, Klein  LW,  et al.  Appropriateness of percutaneous coronary intervention. JAMA. 2011;306(1):53-61.PubMedArticle
2.
Patel  MR, Dehmer  GJ, Hirshfeld  JW, Smith  PK, Spertus  JA.  ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: A Report of 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. Circulation. 2009;119(9):1330-1352.PubMedArticle
3.
Chan  PS, Rao  SV, Bhatt  DL,  et al.  Patient and hospital characteristics associated with inappropriate percutaneous coronary interventions. J Am Coll Cardiol. 2013;62(24):2274-2281.PubMedArticle
4.
Bradley  SM, Maynard  C, Bryson  CL.  Appropriateness of percutaneous coronary interventions in Washington State. Circ Cardiovasc Qual Outcomes. 2012;5(4):445-453.PubMedArticle
5.
Cook  NL, Bonds  DE, Kiefe  CI,  et al; National Heart, Lung, and Blood Institute Centers for Cardiovascular Research (CCOR) Writing Group.  Centers for cardiovascular outcomes research: defining a collaborative vision. Circ Cardiovasc Qual Outcomes. 2013;6(2):223-228.PubMedArticle
6.
Bradley  SM, Chan  PS, Spertus  JA,  et al.  Hospital percutaneous coronary intervention appropriateness and in-hospital procedural outcomes: insights from the NCDR. Circ Cardiovasc Qual Outcomes. 2012;5(3):290-297.PubMedArticle
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Research Letter
December 2015

Patterns of Institutional Review of Percutaneous Coronary Intervention Appropriateness and the Effect on Quality of Care and Clinical Outcomes

Author Affiliations
  • 1Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
  • 2Center for Outcomes Research and Evaluation, Yale–New Haven Health Services Corporation, New Haven, Connecticut
  • 3Division of Cardiology, University of Colorado School of Medicine, Aurora
  • 4Division of Cardiovascular Diseases, University of Michigan, Ann Arbor
  • 5Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan
JAMA Intern Med. 2015;175(12):1988-1990. doi:10.1001/jamainternmed.2015.6217

More than 600 000 percutaneous coronary interventions (PCIs) are performed each year, accounting for more than $12 billion in health care spending.1 In 2009, the American College of Cardiology, American Heart Association, and several other professional organizations released appropriate use criteria (AUC) for coronary revascularization2 designed to support better selection of patients for PCI. Prior studies1,3,4 suggest that as many as 1 in 6 nonacute PCIs may be inappropriate (rarely appropriate). Although the AUC have received substantial attention, little is known about how institutions have responded to them, specifically whether they have developed mechanisms for internal review of PCI appropriateness. Furthermore, whether these review practices are associated with differences in procedural appropriateness, quality of care, and patient outcomes remains uncertain.

Methods

The Translating Outstanding Performance in Percutaneous Coronary Intervention study5 surveyed 500 hospitals regarding processes of PCI care and included detailed questions about institutional practices regarding review of PCI appropriateness from January 1, 2010, through December 31, 2012. Hospitals were stratified based on the frequency of their appropriateness review (no review, daily to monthly review, quarterly review, or unknown review frequency). Appropriateness of PCI was determined for all patients undergoing nonacute PCI at participating hospitals using data from the National Cardiovascular Data Registry’s CathPCI Registry and applying validated algorithms based on the 2012 AUC. Use of guideline-recommended pharmacotherapy, in-hospital mortality, and periprocedural bleeding complications were assessed. Additional analyses examining the association of procedural appropriateness with clinical outcomes and the association between nonacute PCI volume with procedural appropriateness, review frequency, and clinical outcomes were conducted.

Results

A total of 129 539 patients undergoing nonacute PCI at 387 hospitals were included in the analysis. Among these hospitals, 101 (26.1%) reported no review of PCI appropriateness, 104 (26.9%) reported daily to monthly review, 136 (35.1%) reported quarterly review, and 46 (11.9%) did not report a frequency for their review of appropriateness. No significant differences were found in PCI volume, hospital ownership status, or teaching or safety-net status across appropriateness review groups (Table). Overall, 10 722 nonacute PCIs (8.3%) were rarely appropriate, 29 768 (23.0%) were maybe appropriate, and 55 408 (42.8%) were appropriate, with 33 641 (26.0%) nonmappable. Significant hospital variation was found in the proportion of PCIs considered rarely appropriate, but this proportion did not vary significantly by the frequency of AUC review (median proportion of rarely appropriate PCIs, 7.3%-8.3%; Figure, A). Review practices were not associated with differences in the use of guideline-recommended pharmacotherapy, in-hospital mortality, or periprocedural bleeding complications (Table). Rates of in-hospital mortality and periprocedural bleeding were low and did not differ after stratifying hospitals into tertiles based upon the proportion of PCI classified as rarely appropriate. In the lowest tertile, 3.5% of procedures were considered rarely appropriate, and the corresponding in-hospital bleeding and mortality rates were 0.6% and 0.2%, respectively. In contrast, in the highest tertile, 15.8% of procedures were considered rarely appropriate, and in-hospital bleeding and mortality rates were 1.2% and 0.4%, respectively (P value for all comparisons >.05). When considered as a continuous variable, hospitals’ proportion of rarely appropriate PCIs was weakly associated with both in-hospital mortality or periprocedural bleeding (Spearman’s correlation coefficient of 0.10 and 0.15, respectively). There was a modest inverse association between hospitals’ volume of non-acute PCI and the proportion of rarely appropriate PCI (Spearman’s correlation coefficient of −0.09). Compared with hospitals with lower non-acute PCI volume (≤200 cases), hospitals with higher non-acute PCI volume (>200 cases) had lower rates of rarely appropriate PCI across each review frequency (Figure, B).

Discussion

We found marked heterogeneity in patterns of institutional review of PCI appropriateness, with almost 1 in 4 hospitals reporting no review. Moreover, we observed marked variation in the proportion of rarely appropriate PCI across institutions. However, no association was found between hospital review of PCI appropriateness with procedural appropriateness, use of guideline-recommended care, or clinical outcomes.

The AUC for coronary revascularization provide patients, health care professionals, payers, and policymakers with an opportunity to critically examine clinical practice patterns and decision making about patient selection for PCI with the hope of reducing rates of rarely appropriate PCIs while improving patient outcomes. Our finding that a quarter of hospitals do not conduct reviews of AUC suggests that many hospitals have not prioritized improving their performance on AUC. Whether the continued incorporation of PCI appropriateness into public reporting and pay-for-performance programs further incentivizes institutional efforts to improve patient selection for PCI deserves further study.

The presence of regular review alone may be insufficient to improve procedural appropriateness. We observed that differences in institutional PCI appropriateness review were not associated with hospitals’ rates of rarely appropriate PCI. This finding may reflect the fact that the frequency of appropriateness review is a limited measure of the intensity of an institution’s response to the AUC and the reality that review of AUC must be coupled with other enabling structures to be effective. Our survey instrument did not systematically collect additional details of review, including the nature of appropriateness review (prospective or retrospective) or the specific format of the review process.

Consistent with prior studies,1,6 there was a modest association between procedural appropriateness and clinical outcomes and a similarly modest correlation between nonacute PCI volume and procedural appropriateness. Of note, hospitals with a higher volume of nonacute PCI had a lower proportion of rarely appropriate PCI across all review frequencies. Whether this finding is related to the presence of better communication, leadership, and oversight at higher-volume PCI centers is unclear. There is a pressing need to identify effective strategies that can be used to support institutional improvement of PCI appropriateness.

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Article Information

Corresponding Author: Jeptha P. Curtis, MD, Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, PO Box 208017, New Haven, CT 06520-8017 (jeptha.curtis@yale.edu).

Published Online: November 9, 2015. doi:10.1001/jamainternmed.2015.6217.

Author Contributions: Drs Desai and Curtis had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Desai, Curtis.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Desai, Parzynski.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Parzynski.

Obtained funding: Desai, Curtis.

Administrative, technical, or material support: Desai, Minges, Messenger.

Conflict of Interest Disclosures: Drs Desai and Krumholz reported receiving a research agreement from Johnson & Johnson, through Yale University, to develop methods of clinical trial data sharing. Drs Desai, Krumholz, and Curtis reported receiving funding from the Centers for Medicare & Medicaid Services to develop and maintain performance measures that are used for public reporting. Dr Krumholz reported receiving research support from Medtronic, through Yale University, to develop methods of clinical trial data sharing and of a grant from the US Food and Drug Administration to develop methods for postmarket surveillance of medical devices. Dr Krumholz reported chairing a cardiac scientific advisory board for UnitedHealth. Dr Curtis reported holding equity interest in Medtronic. No other disclosures were reported.

Funding/Support: This study was supported by the National Cardiovascular Data Registry (Mr Parzynski and Dr Curtis), grant K12 HS023000-01 from the Agency for Healthcare Research and Quality (Dr Desai), and grant U01 HL105270-05 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute (Drs Krumholz and Curtis and Mr Minges).

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

Additional Information: The National Cardiovascular Data Registry’s CathPCI Registry is an initiative of the American College of Cardiology Foundation and the Society for Cardiovascular Angiography and Interventions.

References
1.
Chan  PS, Patel  MR, Klein  LW,  et al.  Appropriateness of percutaneous coronary intervention. JAMA. 2011;306(1):53-61.PubMedArticle
2.
Patel  MR, Dehmer  GJ, Hirshfeld  JW, Smith  PK, Spertus  JA.  ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: A Report of 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. Circulation. 2009;119(9):1330-1352.PubMedArticle
3.
Chan  PS, Rao  SV, Bhatt  DL,  et al.  Patient and hospital characteristics associated with inappropriate percutaneous coronary interventions. J Am Coll Cardiol. 2013;62(24):2274-2281.PubMedArticle
4.
Bradley  SM, Maynard  C, Bryson  CL.  Appropriateness of percutaneous coronary interventions in Washington State. Circ Cardiovasc Qual Outcomes. 2012;5(4):445-453.PubMedArticle
5.
Cook  NL, Bonds  DE, Kiefe  CI,  et al; National Heart, Lung, and Blood Institute Centers for Cardiovascular Research (CCOR) Writing Group.  Centers for cardiovascular outcomes research: defining a collaborative vision. Circ Cardiovasc Qual Outcomes. 2013;6(2):223-228.PubMedArticle
6.
Bradley  SM, Chan  PS, Spertus  JA,  et al.  Hospital percutaneous coronary intervention appropriateness and in-hospital procedural outcomes: insights from the NCDR. Circ Cardiovasc Qual Outcomes. 2012;5(3):290-297.PubMedArticle
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