The USA saw a 10% decline in percutaneous coronary intervention (PCI) procedures between 2010 and 2017, research published in JAMA Cardiology indicates.
The figures are reported in a research letter authored by Zaid Almarzooq (Harvard Medical School, Boston, USA) and colleagues, who note that there was also a substantial shift of elective PCI from the inpatient to outpatient setting.
According to Almarzooq and colleagues, incidence rates of myocardial infarction (MI) have declined in the USA owing to advancements in preventative care, while more recent randomised trials have supported the role of medical therapy in the initial management of stable ischaemic heart disease.
“Although the epidemiology of MI and practice patterns for stable ischaemic heart disease have changed over time, it remains unclear how these shifts have affected PCI rates,” they write. Their study sought to provide a contemporary assessment of population-level trends in PCI use among all age groups, insurance payers, and hospital settings across four US states.
The study team identified patients who underwent PCI between January 2010 and December 2017 in Florida, Michigan, Maryland, and New York using Healthcare Cost and Utilization Project State Inpatient Databases and State Ambulatory Surgery and Services Databases.
Procedures were classified as urgent if done in the setting of an MI (either ST-elevation or non–ST-elevation MI) or elective in all other circumstances. Overall population rates of PCI were estimated and then stratified by indication (urgent or elective) as well as by setting (inpatient or outpatient), using state population denominators obtained from the US Census Bureau.
The study team found that, in the overall study cohort (333,819 patients [32%] female; mean [SD] age, 65.7 [12.2] years), 1,044,698 PCIs were performed (448,571 [42.9%] were urgent, and 596,127 [57.1%] were elective).
Between 2010 and 2017, PCI rates declined from 260.2 per 100,000 to 232.8 (−10.5%; p for trend <0.001), they report. This was driven entirely by a decrease in elective PCI rates from 165.3 per 100,000 to 123.6 (−34.4%; p for trend<0.001), whereas an increase in urgent PCI rates from 95 per 100,000 in 2010 to 109.2 (+15%; p for trend<0.001) was observed.
The declines in elective PCI occurred primarily between 2010 and 2013 (−23.8%; p for trend <0.001), after which PCI rates remained stable (+1.9%; p for trend =0.496). When stratified by inpatient vs. outpatient setting, inpatient PCI rates decreased from 226.4 per 100,000 to 166.2 (−26.6%; p for trend <0.001), while outpatient PCI rates increased from 33.8 per 100,000 to 66.7 (+97.1%; p for trend <0.001).
Among the underlying factors likely to be behind the trend, Almarzooq and colleagues write that randomised clinical trials such as the COURAGE trial have emphasised the role of medical therapy in the management of stable ischaemic heart disease compared with PCI—although they note that the decline in PCI rates observed in prior years after the publication of the COURAGE trial have since stabilised, potentially owing to waning influence of the trial on clinical practice as well as an increasing population rate of patients with MI undergoing PCI.
“In addition,” they write, “the shift of PCIs from the inpatient to outpatient setting likely reflects changes in payment rules and incentives favouring outpatient procedures, as well as evidence demonstrating safety of same-day discharge after PCI.”