Nihar R Desai (Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, USA) and others report in the Journal of the American Medical Association (JAMA) that following the introduction of appropriate use criteria for coronary revascularisation in 2009, there has been a significant reduction in number of inappropriate percutaneous coronary intervention (PCI) procedures that are performed in the USA.
Desai et al explain that the American College of Cardiology (ACC), American Heart Association (AHA) and other societies collaborated to procedure and publish appropriate use criteria for coronary revascularisation in 2009 to address concerns that PCI was being overused and, in particular, was being used inappropriately (ie. when the benefits of the procedure were unlikely to outweigh the risks). They add that—prior to the publication of the criteria—studies suggested that one in six non-acute PCI procedures were inappropriate and “these findings prompted numerous efforts to improve the appropriateness of PCI”.
The authors comment that “despite the attention that the appropriateness of PCI has received” in recent years, there has not been a systematic study of the appropriateness of PCI procedures being performed in the USA following the introduction of the criteria. They, therefore, “examined national trends in patient selection for PCI, changes in PCI appropriateness, and hospital variation in inappropriate PCI.”
Using data from the National Cardiovascular Data Registry’s CathPCI registry (NCDR, CathPCI), Desai et al identified 2,685,683 PCI procedures that were performed at 766 hospitals between July 2009 and December 2014. Overall, 76.3% of procedures were for acute indications, 14.8% were for non-acute indications, and 8.9% were for non-mappable (ie. not clear if acute or non-acute) indications. They found while the number of acute PCIs that were performed “remained relatively stable over time”, there were significant decreases in the number of non-acute PCIs (from 89,704 in 2010 to 59,375 in 2014; p<0.001) and non-mappable PCIs (from 70,832 in 2010 to 22,589; p<0.001) that were performed. Consequently, Desai et al note, the proportion of acute PCIs that were performed during the study period increased but the proportion of non-acute and unmappable PCIs that were performed decreased.
Furthermore, according to the authors, there was a significant decrease in number of inappropriate non-acute PCIs that were performed between 2009 and 2014 (26.2% in 2009 vs. 13.3% in 2014; p<0.001). The median hospital proportion of inappropriate non-acute PCIs decreased from 25.8% in 2009 to 12.6% in 2014. However, as seen in the previous studies of inappropriate PCI, there was marked variation in the hospital-level proportion of inappropriate non-acute PCI: ranging from 5.9% to 22.9% in 2014 (it ranged from 16.7% to 37.1% in 2009)
The authors comment that their findings suggest “that the practice of interventional cardiology has evolved since the introduction of appropriate use criteria in 2009”. However, they write that they were unable to evaluate the impact of the criteria on the number of inappropriate PCI procedures being performed (ie. if there was a causal link between their introduction and the observed decreased) because the NCDR, CathPCI registry “was not configured to characterise PCI appropriateness until July 2009” and, therefore, their analysis was “limited to cases performed after the release of the appropriate use criteria.” Desai et al add: “It is likely that many factors such as the publication of the COURAGE (Clinical outcomes utilising revascularisation and aggressive drug evaluation) and BARI 2D (Bypass angioplasty revascularisation investigation in type 2 diabetes) trials influenced clinical practice during this timeframe.”
Given that they found that 22% of non-acute PCIs that were performed in 2014 in the “worst performing hospitals” could still be classified as inappropriate, Desai et al state there may be a need “for ongoing performance improvement initiatives and hospital benchmarking.” They add that a potential important area of future research may be to identify the organisational strategies and structures most strongly associated with lower rates of inappropriate PCI.
Desai also presented the study’s findings at the AHA scientific sessions (7–11 October, Orlando, Florida). He told Cardiovascular News: “Over a very short period of time, we have seen dramatic reductions in inappropriate PCI suggesting that the appropriate use criteria have helped improve patient selection for PCI and have had a significant impact on the practice of interventional cardiology. More broadly, this is a testament to leadership and professionalism. Potential overuse of PCI was a difficult issue for cardiologists but one they have responded to directly and swiftly. Professional societies who invested the considerable resources to develop the quality improvement registries and the providers who, within five years, have made dramatic improvements in clinical care for patients deserve to be applauded and recognised for their efforts.”