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Original Investigation
April 8, 2020

Omission of Heart Transplant Recipients From the Appropriate Use Criteria for Revascularization and the Ramifications on Heart Transplant Centers

Author Affiliations
  • 1Emory University School of Medicine, Atlanta, Georgia
  • 2Cedars-Sinai Smidt Heart Institute, Los Angeles, California
  • 3St Luke’s Mid-America Heart Institute, University of Missouri–Kansas City, Kansas City
  • 4Anthem Inc, Richmond, Virginia
  • 5Weill Cornell Medical Center, New York, New York
  • 6Brown University School of Medicine, Providence, Rhode Island
JAMA Cardiol. Published online April 8, 2020. doi:10.1001/jamacardio.2020.0586
Key Points

Question  What proportion of guideline-indicated percutaneous coronary intervention (PCI) procedures in heart transplant recipients are deemed rarely appropriate (RA) per the Appropriate Use Criteria for Revascularization?

Findings  In this study, National Cardiovascular Data Registry CathPCI Registry data from transplant centers showed heart transplant recipients had a higher RA PCI rate from quarter 3 of 2009 to quarter 2 of 2017 vs nonrecipients (66.0% vs 16.9%). Nearly half of transplant centers participating in 1 well-known pay-for-performance program could have benefited from a change in their quality scorecards if their RA PCI rates excluded transplant recipients.

Meaning  Heart transplant centers may be penalized in pay-for-performance programs because the Appropriate Use Criteria for Revascularization omits prior heart transplant as a unique PCI indication.

Abstract

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 Measures  Rates 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.

Results  Of 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.

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