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Varadharajulu SD, Ji RZ, Dhruva SS, Neuhaus J, Redberg RF. A Critical Examination of Independent Medical Review Decision-making for Cardiovascular Procedures Shows Low Rate of Evidence Citation in Reviews. Med Care 2023; 61:737-743. [PMID: 37708360 DOI: 10.1097/mlr.0000000000001912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND The California Independent Medical Review (IMR) program was created in 2001 to provide an independent, external evaluation of insurers' denials of coverage of health services. OBJECTIVE We sought to evaluate the quality and comprehensiveness of data used to support IMR decision-making between 2015 and 2020. RESULTS Of the 159 cases submitted to IMR regarding denials of cardiovascular procedures, 52% of these denials were overturned by IMR, thus restoring coverage. Despite a state-wide requirement that specific references to medical and scientific evidence should be provided in IMR reviews, fewer than a quarter of reviews cited any evidence to support decision-making. Slightly more than one third of IMR review decisions were inconsistent with recommendations from professional societies and peer-reviewed evidence; the primary reason for these inconsistencies was that invasive interventions were often recommended by reviewers before utilizing guideline-directed medical or less invasive therapies. CONCLUSION Our findings highlight an opportunity for improvement in the quality of IMR decision-making through a more consistent use of available scientific evidence to guide clinical reasoning.
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Affiliation(s)
| | - Robin Z Ji
- Department of Medicine, Division of Cardiology, University of California, San Francisco
| | - Sanket S Dhruva
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, University of California, San Francisco School of Medicine
- Philip R. Lee Institute for Health Policy Studies
| | - John Neuhaus
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Rita F Redberg
- Department of Medicine, Division of Cardiology, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies
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2
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Nelson AJ, Inohara T, Rao SV, Kaltenbach LA, Wojdyla D, Wang TY. Comparing the Classification of Percutaneous Coronary Interventions Using the 2012 and 2017 Appropriate Use Criteria: Insights From 245,196 Patients in the NCDR CathPCI Registry. Am Heart J 2023; 255:117-124. [PMID: 36220357 DOI: 10.1016/j.ahj.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/26/2022] [Accepted: 10/01/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Appropriate use criteria (AUC) have been developed to promote the rational use of percutaneous coronary intervention (PCI) among clinicians and to provide benchmarking feedback to hospitals. The original AUC were published in 2012 and subsequently updated in 2017 to reflect emerging, contemporary evidence however the degree to which the updated guidance re-classifies PCI appropriateness is unknown. METHODS Elective PCI cases from March 1, 2018 until June 30, 2021 were identified from within the NCDR CathPCI database. PCI cases were classified as 'appropriate,' 'uncertain' or 'inappropriate' under 2012 AUC and 'appropriate,' 'may be appropriate' or 'rarely appropriate' under 2017 AUC; those with missing data elements were termed 'not mappable.' Groups that 'remained appropriate' (appropriate in both 2012 and 2017), 'became non-appropriate' ('appropriate' in 2012 but became either 'may be appropriate' or 'rarely appropriate in 2017) and 'became appropriate' ('appropriate' in 2017 but were 'uncertain' or 'inappropriate' in 2012) were descriptively compared. Concordance was assessed by calculation of Cohen's Kappa. RESULTS A total of 245,196 patients underwent elective PCI across 1669 centers. By 2012 AUC, 44% were classified 'appropriate,' 28% were 'uncertain' and 16% were 'inappropriate' compared with 2017 AUC which considered 34% 'appropriate', 56% may be 'appropriate' and 4% 'rarely appropriate'. Overall fair agreement was observed with a Kappa statistic of 0.40 (95%CI 0.396-0.403). Compared with PCI that 'remained appropriate' under the 2017 AUC, PCI that 'became non-appropriate' in 2017 were more likely to be asymptomatic, less likely to be on anti-anginals and less likely to have complex lesions. Compared with PCI that 'became non-appropriate', PCI that 'became appropriate' had a higher proportion of atypical and non-anginal symptoms and were less likely to have had positive functional tests. Procedural related outcomes were similar across all groups. A total of 29 429 PCI (12.0%) were not mappable by 2012 AUC while 16 077 (6.6%) were not mappable by 2017 AUC. CONCLUSIONS In this contemporary analysis of patients undergoing PCI in the United States, only fair agreement between the 2012 and updated 2017 AUC was observed. While some of this reflects the intention of the updated guidance, the large proportion that were considered 'maybe appropriate' or who 'became non-appropriate' reflect the difficulties of documenting and implementing contemporary AUC guidance.
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Affiliation(s)
- Adam J Nelson
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
| | - Taku Inohara
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Sunil V Rao
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Lisa A Kaltenbach
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Daniel Wojdyla
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Tracy Y Wang
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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3
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Shoji S, Yamaji K, Sandhu AT, Ikemura N, Shiraishi Y, Inohara T, Heidenreich PA, Amano T, Ikari Y, Kohsaka S. Regional variations in the process of care for patients undergoing percutaneous coronary intervention in Japan. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 22:100425. [PMID: 35308578 PMCID: PMC8928076 DOI: 10.1016/j.lanwpc.2022.100425] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Measuring the quality of care has been central for improving the outcomes of patients undergoing percutaneous coronary intervention (PCI). This study described the performance rates and regional variations in quality metrics for PCI using a representative national Japanese registry. Methods Overall, 760,854 patients across 714 institutions (2016-2018) were analysed. Quality metrics included preprocedural antiplatelet therapy use, door-to-balloon time ≤90 min for ST-elevation myocardial infarction, transradial approach, and preprocedural noninvasive stress testing for elective cases in 47 Japanese prefectures. Coronary computed tomography angiography (CCTA) and fractional flow reserve (FFR) were also evaluated. Factors associated with preprocedural testing rates were evaluated using multivariable linear regression. Findings Rates of preprocedural antiplatelet therapy use were high with low variations (96·4% [94·7-97·2%]), but there was still substantial room for improvement in the rates of door-to-balloon time (74·7% [71·2-78·9%]) and transradial approach use (70·9% [65·1-73·4%]). Rates of preprocedural noninvasive stress testing were low with substantial variation (36·6% [27·1-49·7%]). Additionally, we found substantial variations in CCTA (50·0% [39·5-55·1%]) and FFR measurement (15·7% [113·-18·3%]) rates. The number of scintigraphy scanners/ prefecture was associated with the performance of noninvasive stress testing (13·4% [95% CI, 2·45-24·4%] increase for every 1/100,000 population increase in scanners). Interpretations We observed substantial regional variation in the use of preprocedural testing, and its performance was directly related to nuclear-scanner availability. These findings suggest the need for targeted efforts in improving testing rates, whether by optimising resource allocation or additional education or feedback mechanisms. Funding This study was funded by the Japan Society for the Promotion of Science (Grant Nos. 20H03915, 16H05215, 16KK0186, and 20K22883) and by the Ministry of Health, Labor and Welfare Grants-in-Aid for Scientific Research Program (Grant No. 21FA1015). The J-PCI registry is led and supported by the Japanese Association of Cardiovascular Intervention and Therapeutics.
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Affiliation(s)
- Satoshi Shoji
- Department of Cardiology, Hino Municipal Hospital, Tokyo, Japan
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kyohei Yamaji
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Alexander T. Sandhu
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, CA, USA
| | - Nobuhiro Ikemura
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Paul A. Heidenreich
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, CA, USA
- Medical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Aichi, Japan
| | - Yuji Ikari
- Department of Cardiology, Tokai University School of Medicine, Kanagawa, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
- Corresponding author.
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Guduguntla V, Redberg RF. Popular procedures without evidence of benefit: A case study of percutaneous coronary intervention for stable coronary artery disease. Eur J Intern Med 2021; 94:15-21. [PMID: 34535375 DOI: 10.1016/j.ejim.2021.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 08/24/2021] [Accepted: 08/31/2021] [Indexed: 01/09/2023]
Abstract
Despite limited benefit, percutaneous coronary intervention (PCI) remains a common procedure that is often performed for uncertain or inappropriate indications in patients with stable coronary artery disease (CAD). PCI cases per capita have increased year-over-year in most European countries, and many have higher rates than the U.S. Meanwhile, first-line therapy such as optimal medical therapy (OMT) and lifestyle changes, continue to be under-utilized. This article reviews the evidence on use of PCI in stable CAD. Specifically, we analyzed randomized control trials, systematic reviews, appropriate use criteria, and professional society guidelines that examine the risks and benefits of PCI compared to OMT. We then highlight utilization patterns as well as interventions that better align current practice with evidence-based care.
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Affiliation(s)
- Vinay Guduguntla
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94131, United States.
| | - Rita F Redberg
- Department of Cardiology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94131, United States
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5
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Seki T, Tokumasu H, Tanaka H, Katoh H, Kawakami K. Appropriateness of Percutaneous Coronary Intervention Performed by Japanese Expert Operators in Patients With Chronic Total Occlusion. Circ J 2021; 86:799-807. [PMID: 34615814 DOI: 10.1253/circj.cj-21-0483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The appropriateness of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions has rarely been investigated.Methods and Results:The Japanese CTO-PCI Expert Registry enrolled consecutive patients undergoing CTO-PCI carried out by highly experienced Japanese CTO specialists who performed more than 50 CTO-PCIs per year and 300 CTO-PCIs in total. This study included patients undergoing CTO-PCI between January 2014 and December 2019. The appropriateness, trends, and differences among the procedures performed by the operators using the 2017 appropriate use criteria were analyzed. Furthermore, we performed a logistic regression analysis to assess whether the appropriateness was associated with in-hospital major adverse cardiovascular and cerebrovascular events (MACCE). Of the 5,062 patients who underwent CTO-PCI, 4,309 (85.1%) patients who did not undergo the non-invasive stress test were classified as having no myocardial ischemia. Of the total cases, 3,150 (62.2%) were rated as "may be appropriate," and 642 (12.7%) as "rarely appropriate" CTO-PCI cases. The sensitivity analyses showed that the number (%) of "may be appropriate" ranged from 4,125 (57.8%) to 4,744 (66.4%) and the number of "rarely appropriate" ranged from 843 (11.8%) to 970 (13.6%) among best and worst scenarios. CONCLUSIONS In a large Japanese CTO-PCI registry, approximately 13% of CTO-PCI procedures were classified as "rarely appropriate". Substantial efforts would be required to decrease the number of "rarely appropriate" CTO-PCI procedures.
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Affiliation(s)
- Tomotsugu Seki
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University.,Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | | | | | | | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
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6
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Popova YV, Kiselev AR, Sagaydak OV, Posnenkova OM, Gridnev VI, Oshchepkova EV. Application of the Appropriate Use Criteria for Coronary Revascularization in Patients with Acute Coronary Syndrome in the Russian Federation: Data from the Federal Registry. Eurasian J Med 2021; 53:96-101. [PMID: 34177290 DOI: 10.5152/eurasianjmed.2021.20004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective The aim of the study was to apply the appropriate use criteria (AUC) for coronary revascularization on Russian Acute Coronary Syndrome Registry (RusACSR) data to analyze validity of the decision to perform percutaneous coronary interventions (PCIs) among patients with acute coronary syndrome (ACS). Material and Methods In Russia, the frequency of performing PCI increased almost 7.5 times, and more than half of all interventions were performed in patients with ACS, in the period from 2006 to 2015. AUC 2012 were used to assess PCI appropriateness. Data were exported from RusACSR from a period of January 1, 2016 to December 31, 2016. We analyzed 33 893 cases, but 13 957 patients were excluded owing to absence of data needed. The study group therefore included 19 936 patients with ACS (mean age, 65.3 ± 11.9 years; 40.3% women), and it was divided into 2 subgroups: 13 757 (67.2%) patients who were treated conservatively and 6179 (32.8%) patients who underwent PCI. According to AUC, physicians' choice of strategy was validated. Results Patients treated conservatively differed significantly (P < .001) from those who underwent PCI. In this group, non-ST segment elevation ACS was significantly more common than in the group of patients who received PCI (84.4% vs. 43.9%, P < .001). They also had more severe clinical status. According to AUC, among patients with ACS treated with PCI, the decision was warranted in 86.3% (valid decision). In 7.6% of cases, there was no need for PCI. Among patients who underwent conservative treatment, 77.7% of patients needed PCI according to AUC. According to our data, only 3.8% of patients who were treated conservatively did not need PCI. Appropriateness of invasive treatment was uncertain in 18.5% and 6.1% in the PCI and non-PCI groups, respectively. All differences were significant (P < .001). Conclusion AUC implementation showed low availability of PCI for patients with non-ST segment elevation ACS accompanied by complicated clinical status. AUC for coronary revascularization could be applied in Russian clinical practice for unbiased PCI candidate selection and for evaluation of decision validity.
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7
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Yelavarthy P, Seth M, Pielsticker E, Grines CL, Duvernoy CS, Sukul D, Gurm HS. The DISCO study-Does Interventionalists' Sex impact Coronary Outcomes? Catheter Cardiovasc Interv 2021; 98:E531-E539. [PMID: 34000081 DOI: 10.1002/ccd.29774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/30/2021] [Accepted: 05/03/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To examine the association of operator sex with appropriateness and outcomes of percutaneous coronary intervention (PCI). BACKGROUND Recent studies suggest that physician sex may impact outcomes for specific patient cohorts. There are no data evaluating the impact of operator sex on PCI outcomes. METHODS We studied the impact of operator sex on PCI outcome and appropriateness among all patients undergoing PCI between January 2010 and December 2017 at 48 non-federal hospitals in Michigan. We used logistic regression models to adjust for baseline risk among patients treated by male versus female operators in the primary analysis. RESULTS During this time, 18 female interventionalists and 385 male interventionalists had performed at least one PCI. Female interventionalists performed 6362 (2.7%) of 239,420 cases. There were no differences in the odds of mortality (1.48% vs. 1.56%, adjusted OR [aOR] 1.138, 95% CI: 0.891-1.452), acute kidney injury (3.42% vs. 3.28%, aOR 1.027, 95% CI: 0.819-1.288), transfusion (2.59% vs. 2.85%, aOR 1.168, 95% CI: 0.980-1.390) or major bleeding (0.95% vs. 1.07%, aOR 1.083, 95% CI: 0.825-1.420) between patients treated by female versus male interventionalist. While the absolute differences were small, PCIs performed by female interventional cardiologists were more frequently rated as appropriate (86.64% vs. 84.45%, p-value <0.0001). Female interventional cardiologists more frequently prescribed guideline-directed medical therapy. CONCLUSIONS We found no significant differences in risk-adjusted in-hospital outcomes between PCIs performed by female versus male interventional cardiologists in Michigan. Female interventional cardiologists more frequently performed PCI rated as appropriate and had a higher likelihood of prescribing guideline-directed medical therapy.
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Affiliation(s)
- Prasanthi Yelavarthy
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Milan Seth
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Cindy L Grines
- Division of Cardiovascular Medicine, Northside Cardiovascular Institute, Atlanta, Georgia, USA
| | - Claire S Duvernoy
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Cardiovascular Medicine, Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Devraj Sukul
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Cardiovascular Medicine, Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Hitinder S Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Cardiovascular Medicine, Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
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Matsoukis IL, Karanasos A, Patsa C, Anousakis‐Vlachochristou N, Triantafyllou K, Kantzanou M, Drakopoulou M, Tsiamis E, Latsios G, Synetos A, Petridou ET, Tousoulis D, Toutouzas K. Long‐term clinical outcomes of coronary artery bypass graft surgery compared to those of percutaneous coronary intervention with second generation drug eluting stents in patients with stable angina and an isolated lesion in the proximal left anterior descending artery. Catheter Cardiovasc Interv 2020; 98:447-457. [DOI: 10.1002/ccd.29247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/14/2020] [Accepted: 08/17/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Ioannis L. Matsoukis
- Department of Hygiene, Epidemiology and Medical Statistics Athens Medical School Athens Greece
- 1st Cardiology Department Athens Medical School, Hippokration General Hospital Athens Greece
| | - Antonios Karanasos
- 1st Cardiology Department Athens Medical School, Hippokration General Hospital Athens Greece
| | - Chrysoula Patsa
- 1st Cardiology Department Athens Medical School, Hippokration General Hospital Athens Greece
| | | | | | - Maria Kantzanou
- Department of Hygiene, Epidemiology and Medical Statistics Athens Medical School Athens Greece
| | - Maria Drakopoulou
- 1st Cardiology Department Athens Medical School, Hippokration General Hospital Athens Greece
| | - Eleftherios Tsiamis
- 1st Cardiology Department Athens Medical School, Hippokration General Hospital Athens Greece
| | - George Latsios
- 1st Cardiology Department Athens Medical School, Hippokration General Hospital Athens Greece
| | - Andreas Synetos
- 1st Cardiology Department Athens Medical School, Hippokration General Hospital Athens Greece
| | - Eleni Th Petridou
- Department of Hygiene, Epidemiology and Medical Statistics Athens Medical School Athens Greece
- Clinical Epidemiology Unit Karolinska Institute Stockholm Sweden
| | - Dimitris Tousoulis
- 1st Cardiology Department Athens Medical School, Hippokration General Hospital Athens Greece
| | - Konstantinos Toutouzas
- 1st Cardiology Department Athens Medical School, Hippokration General Hospital Athens Greece
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9
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Hess PL, Kini V, Liu W, Roldan P, Autruong P, Grunwald GK, O’Donnell C, Doll JA, Ho PM, Bradley SM. Appropriateness of Percutaneous Coronary Interventions in Patients With Stable Coronary Artery Disease in US Department of Veterans Affairs Hospitals From 2013 to 2015. JAMA Netw Open 2020; 3:e203144. [PMID: 32315067 PMCID: PMC7175080 DOI: 10.1001/jamanetworkopen.2020.3144] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE In hospitals outside of the US Department of Veterans Affairs (VA) system, 1 in 10 percutaneous coronary interventions (PCIs) for stable coronary artery disease is considered rarely appropriate by the appropriate use criteria, with variation across hospitals. The appropriateness of PCIs in VA hospitals has not been documented. OBJECTIVE To characterize the appropriateness of PCIs in VA hospitals. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients with stable coronary artery disease undergoing elective PCI from November 1, 2013, to October 31, 2015, within the VA Clinical Assessment, Reporting, and Tracking Program, an operational program that includes 59 VA hospitals. Data were analyzed from March 1, 2019, to August 8, 2019. EXPOSURES Elective PCI at a VA hospital. MAIN OUTCOMES AND MEASURES Proportion of PCIs classified as appropriate, may be appropriate, or rarely appropriate; extent of hospital-level variation in rarely appropriate PCIs using criteria issued by cardiovascular professional societies in 2012. The extent of hospital-level variation in rates of rarely appropriate PCI was characterized using hospital proportions and random-effect logistic regression. RESULTS Among 2611 patients undergoing elective PCI (mean [SD] age, 66.3 [7.6] years; 2577 [98.7%] men) at 59 hospitals, a total of 778 PCIs (29.8%) were classified as appropriate, 1561 PCIs (59.8%) were classified as may be appropriate, and 272 PCIs (10.4%) were classified as rarely appropriate. Rarely appropriate PCIs were more commonly performed in patients who had low-risk stress test findings (220 patients [89.1%]), who were taking no (100 patients [36.8%]) or 1 (167 patients [61.4%]) antianginal medication, or who had 1 coronary artery stenosis (185 patients [68.0%]). The unadjusted hospital-level rates of rarely appropriate PCIs ranged from 0% to 28.6%, with a median (interquartile range) of 9.7% (6.3%-13.9%). Random-effect models yielded an estimated median (interquartile range) rate of rarely appropriate PCI of 10.4% (8.7%-12.3%). CONCLUSIONS AND RELEVANCE These findings suggest that in VA practice, most PCIs for stable coronary artery disease were classified as appropriate or may be appropriate. However, 1 in 10 PCIs was classified as rarely appropriate, with variation across VA hospitals. Efforts to improve patient selection are needed.
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Affiliation(s)
- Paul L. Hess
- University of Colorado Anschutz Medical Campus, Aurora
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Vinay Kini
- University of Colorado Anschutz Medical Campus, Aurora
| | - Wenhui Liu
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | | | | | - Gary K. Grunwald
- University of Colorado Anschutz Medical Campus, Aurora
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Colin O’Donnell
- University of Colorado Anschutz Medical Campus, Aurora
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Jacob A. Doll
- VA Puget Sound Health Care System, Seattle, Washington
| | - P. Michael Ho
- University of Colorado Anschutz Medical Campus, Aurora
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
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Chmiel C, Reich O, Signorell A, Neuner-Jehle S, Rosemann T, Senn O. Effects of managed care on the proportion of inappropriate elective diagnostic coronary angiographies in non-emergency patients in Switzerland: a retrospective cross-sectional analysis. BMJ Open 2018; 8:e020388. [PMID: 30478102 PMCID: PMC6254409 DOI: 10.1136/bmjopen-2017-020388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Guidelines recommend non-invasive ischaemia testing (NIIT) for the majority of patients with suspected ischaemic heart disease in a non-emergency setting. A substantial number of these patients undergo diagnostic coronary angiography (CA) without therapeutic intervention inappropriately due to lacking preceding NIIT. The aim of this study was to evaluate the effect of voluntary healthcare models with limited access on the proportion of patients without NIIT prior to elective purely diagnostic CA. DESIGN Retrospective cross-sectional analysis of insurance claims data from 2012 to 2015. Data included claims of basic and voluntary healthcare models from approximately 1.2 million patients enrolled with the Helsana Insurance Group. Voluntary healthcare models with limited health access are divided into gate keeping (GK) and managed care (MC) capitation models. INCLUSION CRITERIA patients undergoing CA. EXCLUSION CRITERIA Patients<18 years, incomplete health insurance data coverage, acute cardiac ischaemia and emergency procedures, therapeutic CA (coronary angioplasty/stenting or coronary artery bypass grafting). The effect of voluntary healthcare models on the proportion of NIIT undertaken within 2 months before diagnostic CA was assessed by means of multiple logistic regression analysis, controlled for influencing factors. RESULTS 9173 patients matched inclusion criteria. 33.2% (3044) did not receive NIIT before CA. Compared with basic healthcare models, MC was independently associated with a higher proportion of NIIT (p<0.001, OR 1.17, CI 1.045 to 1.312), when additionally controlled for demographics, insurance coverage, inpatient treatment, cardiovascular medication, chronic comorbidities, high-risk status (patients with therapeutic cardiac intervention 1 month after or 18 months prior to diagnostic CA). GK models showed no significant association with the rate of NIIT (p=0.07, OR 1.11, CI 0.991 to 1.253). CONCLUSIONS In a non-GK healthcare system, voluntary MC healthcare models with capitation were associated with a reduced inappropriate use of diagnostic CA compared with GK or basic models.
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Affiliation(s)
- Corinne Chmiel
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Oliver Reich
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Andri Signorell
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | | | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
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11
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Lambert-Kerzner A, Maynard C, McCreight M, Ladebue A, Williams KM, Fehling KB, Bradley SM. Assessment of barriers and facilitators in the implementation of appropriate use criteria for elective percutaneous coronary interventions: a qualitative study. BMC Cardiovasc Disord 2018; 18:164. [PMID: 30103677 PMCID: PMC6205154 DOI: 10.1186/s12872-018-0901-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 08/01/2018] [Indexed: 11/22/2022] Open
Abstract
Background The use of inappropriate elective Percutaneous Coronary Intervention (PCI) has decreased over time, but hospital-level variation in the use of inappropriate PCI persists. Understanding the barriers and facilitators to the implementation of Appropriate Use Criteria (AUC) guidelines may inform efforts to improve elective PCI appropriateness. Methods All hospitals performing PCI in Washington State were categorized by their use of inappropriate elective PCI in 2010 to 2013. Semi-structured, qualitative telephone interviews were then conducted with 17 individual interviews at 13 sites in Washington State to identify barriers and facilitators to the implementation of the AUC guidelines. An inductive and deductive, team-based analytical approach, drawing primarily on Matrix analysis was performed to identify factors affecting implementation of the AUC. Results Specific facilitators were identified that supported successful implementation of the AUC. These included collaborative catheterization laboratory environments that allow all staff to participate with questions and opinions; ongoing AUC education with catheterization laboratory teams and referring providers; internal AUC peer review processes; interventional cardiologist be directly involved with the pre-procedural review process; checklist-based algorithms for pre-procedural documentation; systems redesign to include insurance companies; and AUC educational information with patients. Barriers to implementation of the AUC included external pressures, such as competition for patients, and the lack of shared medical records with sites that referred patients for coronary angiography. Conclusions The identified facilitators enabled sites to successfully implement the AUC. Catheterization laboratories struggling to successfully implement the AUC may consider utilizing these strategies to improve their processes to improve patient selection for elective PCI.
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Affiliation(s)
- Anne Lambert-Kerzner
- VA Eastern Colorado Health Care System, Department of Veterans Affairs Medical Center, Denver, CO, USA. .,Minneapolis Heart Institute, Minneapolis, MN, USA.
| | - Charles Maynard
- VA Eastern Colorado Health Care System, Department of Veterans Affairs Medical Center, Denver, CO, USA.,School of Public Health, University of Colorado, Aurora, CO, USA
| | - Marina McCreight
- Foundation for Health Care Quality Clinical Outcomes Assessment Program, Seattle, WA, USA
| | - Amy Ladebue
- VA Eastern Colorado Health Care System, Department of Veterans Affairs Medical Center, Denver, CO, USA
| | - Katherine M Williams
- VA Eastern Colorado Health Care System, Department of Veterans Affairs Medical Center, Denver, CO, USA
| | - Kelty B Fehling
- VA Eastern Colorado Health Care System, Department of Veterans Affairs Medical Center, Denver, CO, USA
| | - Steven M Bradley
- VA Eastern Colorado Health Care System, Department of Veterans Affairs Medical Center, Denver, CO, USA.,Minneapolis Heart Institute, Minneapolis, MN, USA
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Alyesh DM, Seth M, Miller DC, Dupree JM, Syrjamaki J, Sukul D, Dixon S, Kerr EA, Gurm HS, Nallamothu BK. Exploring the Healthcare Value of Percutaneous Coronary Intervention: Appropriateness, Outcomes, and Costs in Michigan Hospitals. Circ Cardiovasc Qual Outcomes 2018; 11:e004328. [PMID: 29853465 PMCID: PMC7053780 DOI: 10.1161/circoutcomes.117.004328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 04/26/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Assessments of healthcare value have largely focused on measuring outcomes of care at a given level of cost with less attention paid to appropriateness. However, understanding how appropriateness relates to outcomes and costs is essential to determining healthcare value. METHODS AND RESULTS In a retrospective cohort study design, administrative data from fee-for-service Medicare patients undergoing percutaneous coronary intervention (PCI) in Michigan hospitals between June 30, 2010, and December 31, 2014, were linked with clinical data from a statewide PCI registry to calculate hospital-level measures of (1) appropriate use criteria scores, (2) 90-day risk-standardized readmission and mortality rates, and (3) 90-day risk-standardized episode costs. We then used Spearman correlation coefficients to assess the relationship between these measures. A total of 29 839 PCIs were performed at 33 PCI hospitals during the study period. A total of 13.3% were for ST-segment-elevation myocardial infarction, 25.0% for non-ST-segment-elevation myocardial infarction, 47.1% for unstable angina, 9.8% for stable angina, and 4.7% for other. The overall hospital-level mean appropriate use criteria score was 8.4±0.2. Ninety-day risk-standardized readmission occurred in 23.7%±3.7% of cases, 90-day risk-standardized mortality in 4.3%±0.6%, and mean risk-standardized episode costs were $26 159±$1074. Hospital-level appropriate use criteria scores did not correlate with 90-day readmission, mortality, or episode costs. CONCLUSIONS Among Medicare patients undergoing PCI in Michigan, we found hospital-level appropriate use criteria scores did not correlate with 90-day readmission, mortality, or episode costs. This finding suggests that a comprehensive understanding of healthcare value requires multidimensional consideration of appropriateness, outcomes, and costs.
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Affiliation(s)
- Daniel M Alyesh
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.M.A., D.S., H.S.G., B.K.N.)
| | - Milan Seth
- University of Michigan Medical School, Ann Arbor. Blue Cross Blue Shield of Michigan Cardiovascular Collaborative, Ann Arbor, MI (M.S., H.S.G.)
| | - David C Miller
- Department of Urology (D.C.M., J.M.D., J.S.)
- Blue Cross Blue Shield Michigan Value Collaborative, Ann Arbor, MI (D.C.M., J.M.D., J.S.)
| | - James M Dupree
- Department of Urology (D.C.M., J.M.D., J.S.)
- Blue Cross Blue Shield Michigan Value Collaborative, Ann Arbor, MI (D.C.M., J.M.D., J.S.)
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., E.A.K., B.K.N. J.M.D.)
| | - John Syrjamaki
- Department of Urology (D.C.M., J.M.D., J.S.)
- Blue Cross Blue Shield Michigan Value Collaborative, Ann Arbor, MI (D.C.M., J.M.D., J.S.)
| | - Devraj Sukul
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.M.A., D.S., H.S.G., B.K.N.)
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., E.A.K., B.K.N. J.M.D.)
| | - Simon Dixon
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, MI (S.D.)
| | - Eve A Kerr
- Ann Arbor Veterans Affairs Center for Clinical Management Research, MI (E.A.K., H.S.G., B.K.N.)
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., E.A.K., B.K.N. J.M.D.)
| | - Hitinder S Gurm
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.M.A., D.S., H.S.G., B.K.N.)
- University of Michigan Medical School, Ann Arbor. Blue Cross Blue Shield of Michigan Cardiovascular Collaborative, Ann Arbor, MI (M.S., H.S.G.)
- Ann Arbor Veterans Affairs Center for Clinical Management Research, MI (E.A.K., H.S.G., B.K.N.)
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Medicine, Department of Internal Medicine (D.M.A., D.S., H.S.G., B.K.N.)
- Ann Arbor Veterans Affairs Center for Clinical Management Research, MI (E.A.K., H.S.G., B.K.N.)
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., E.A.K., B.K.N. J.M.D.)
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Appropriateness of elective percutaneous coronary intervention and impact of government health insurance scheme - A tertiary centre experience from Western India. Indian Heart J 2017; 69:600-606. [PMID: 29054183 PMCID: PMC5650591 DOI: 10.1016/j.ihj.2016.12.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/21/2016] [Accepted: 12/26/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There is a dearth of data regarding the appropriateness of elective percutaneous coronary intervention (PCI) in a limited-resource country such as India. In an attempt to rationalise the use of PCI, Appropriate Use Criteria (AUC) were developed for cardiovascular care in the USA. In the Indian context, considering the high prevalence of coronary artery disease, the dramatic rise in the number of revascularization procedures and an increasing role of government/private reimbursements, application of AUC could potentially guide policy to optimize the utilization of resources and the benefit-risk ratio for individual patients. OBJECTIVES The study sought to determine the overall and year-wise trends in the appropriateness of elective PCI using the AUC and also understand the impact of the government health insurance scheme (GHIS). MATERIAL AND METHODS The inpatient records of all patients undergoing elective PCI, at a single large tertiary care centre in Western India, from January 2009 to December 2014 were retrospectively analysed (n=972, 759 males, 213 females) by a neutral observer. The AUC scores and subsequent ranking were calculated using the dedicated web-based software and each PCIwas ranked as either 'appropriate', 'uncertain' or 'inappropriate'. Elective PCI performed within a month after the index acute coronary syndrome (ACS) was considered as 'ACS' while applying the AUC. All other indications were considered as 'non-ACS'. Nearly 95% of elective PCI performed after July 2012 were covered under theGHIS and therefore the period January 2009-June 2012 was compared with the July 2012- December 2014 to assess the impact of this scheme. RESULTS A total of 894 elective PCI (379 and 515 PCI in the ACS setting and non-ACS setting respectively) performed on 857 patients were analysed. The elective PCI performed in the pre-GHIS and GHIS period were 458 and 436 respectively. As per AUC, 352 (39.6 ± 4.4 %) of the overall elective PCI were ranked as 'appropriate', while 487 (55.3 ± 4.1 %) cases as 'uncertain' and 55 (5.1 ± 0.6 %) cases as 'inappropriate'. An overall year-wise temporal trend in the proportion of cases in any of the AUC rankings did not show any significant trends(p > 0.05). However, 80.4 ± 7.3 % of elective PCI in the ACS setting were categorised as 'appropriate' and 82.6 ± 6.9 % of elective PCI in non-ACS setting were ranked as 'uncertain'. With state-wide implementation of the GHIS, the total number of elective PCI increased by 50% (436 in the 3½ year pre-GHIS study period as against 458 in the 2½ year GHIS study period). The introduction of GHIS led to a marginal increase (p > 0.05) in the average annual number of elective PCI in non-ACS setting as opposed to a 120% rise in the number of elective PCI done in the ACS setting (p < 0.001) and the delay in performing PCI after coronary angiogram reduced from 55.8 ± 43.6 days to 33 ± 22.9 days (p < 0.01). Also, the ratio of men: women undergoing elective PCI rationalised from 5.4:1 to 2.7:1 (p < 0.001). With the introduction of the GHIS, the share of 'inappropriate' elective PCI in the ACS setting increased from 1.34 % to 4.81 % (p =0.065). However, there was also a fall in 'appropriate' elective PCI in the non-ACS setting from 15.0 ± 3.2% to 7 ± 1.6% (p < 0.001). CONCLUSION On applying the 2012 updated AUC, about 5 % of overall elective PCI were deemed as 'inappropriate'. About four in every five elective PCI in the non-ACS setting were of 'uncertain' appropriateness. The implementation of the GHIS not only significantly reduced the gender bias and delay in seeking interventional coronary care but also led to a significant rise in the proportion of PCI performed in the ACS setting. However, there was also a rise in 'inappropriate' PCI in the ACS setting and a significant fall in 'appropriate' PCI in the non-ACS setting after introduction of the GHIS..
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Liang FW, Lu TH, Wu HM, Lee JC, Yin WH. Regional and hospital variations in the extent of decline in the proportion of percutaneous coronary interventions performed for nonacute indications - a nationwide population-based study. BMC Cardiovasc Disord 2017; 17:149. [PMID: 28599642 PMCID: PMC5466717 DOI: 10.1186/s12872-017-0592-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 06/05/2017] [Indexed: 11/26/2022] Open
Abstract
Background The volume and percentage of percutaneous coronary interventions (PCIs) performed for nonacute indications have declined in the United States since 2007. However, little is known if similar trends occurred in Taiwan. Methods We used data from Taiwan National Health Insurance inpatient claims to examine the regional and hospital variations in the extent of decline in the percentage of nonacute indication PCIs from 2007 to 2012. Results The volume of total PCIs persistently increased from 29,032 in 2007 to 35,811 in 2010 and 37,426 in 2012. However, the volume of nonacute indication PCIs first increased from 7916 in 2007 to 9143 in 2009 and then decreased to 8666 in 2012. The percentage of nonacute indication PCIs steadily decreased from 27% in 2007 to 26% in 2009 and then to 23% in 2012, a − 15% change. The extent of decline was largest in the North region (from 27% to 21%, a − 22% change) and least in Kaopin region (from 20% to 18%, a − 13% change). Of the 71 hospitals studied, 14 did not show a decreasing trend. Five of the 14 hospitals even showed an increasing trend, with a percentage change >10% between 2007 and 2012. In 2012, 6 hospitals had a nonacute indication PCI percentage >35%. Conclusions In Taiwan, four-fifths of the hospitals showed a decline in the percentage of nonacute indication PCIs from 2007 to 2012. It is plausible that Taiwanese cardiologists would have been influenced by the recommendations of crucial US trials and guidelines.
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Affiliation(s)
- Fu-Wen Liang
- The NCKU Research Center for Health Data and Department of Public Health, National Cheng Kung University, No. 1, University Road, East District, Tainan, 70101, Taiwan
| | - Tsung-Hsueh Lu
- The NCKU Research Center for Health Data and Department of Public Health, National Cheng Kung University, No. 1, University Road, East District, Tainan, 70101, Taiwan
| | - Hsin-Min Wu
- The NCKU Research Center for Health Data and Department of Public Health, National Cheng Kung University, No. 1, University Road, East District, Tainan, 70101, Taiwan
| | - Jo-Chi Lee
- The NCKU Research Center for Health Data and Department of Public Health, National Cheng Kung University, No. 1, University Road, East District, Tainan, 70101, Taiwan
| | - Wei-Hsian Yin
- Division of Cardiology, Cheng Hsin General Hospital, No. 45, Cheng Hsin Street, Bei-Tou, Taipei, 11220, Taiwan. .,School of Medicine, National Yang Ming University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan.
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Finkelstein A, Minha S, Kornowski R, Danenberg H, Banai S, Lotan H, Segev A, Barbash I. Israel: coronary and structural heart interventions from 2010 to 2015. EUROINTERVENTION 2017; 13:Z32-Z36. [DOI: 10.4244/eij-d-16-00835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Hannan EL, Samadashvili Z, Cozzens K, Gesten F, Osinaga A, Fish DG, Donahue CL, Bass RJ, Walford G, Jacobs AK, Venditti FJ, Stamato NJ, Berger PB, Sharma S, King SB. Changes in Percutaneous Coronary Interventions Deemed “Inappropriate” by Appropriate Use Criteria. J Am Coll Cardiol 2017; 69:1234-1242. [DOI: 10.1016/j.jacc.2016.12.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/30/2016] [Accepted: 12/08/2016] [Indexed: 10/20/2022]
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Toyota T, Morimoto T, Shiomi H, Ando K, Ono K, Shizuta S, Kato T, Saito N, Furukawa Y, Nakagawa Y, Horie M, Kimura T. Ad hoc vs. Non-ad hoc Percutaneous Coronary Intervention Strategies in Patients With Stable Coronary Artery Disease. Circ J 2017; 81:458-467. [PMID: 28179612 DOI: 10.1253/circj.cj-16-0987] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Few studies have evaluated the prevalence and clinical outcomes of ad hoc percutaneous coronary intervention (PCI), performing diagnostic coronary angiography and PCI in the same session, in stable coronary artery disease (CAD) patients.Methods and Results:From the CREDO-Kyoto PCI/CABG registry cohort-2, 6,943 patients were analyzed as having stable CAD and undergoing first PCI. Ad hoc PCI and non-ad hoc PCI were performed in 1,722 (24.8%) and 5,221 (75.1%) patients, respectively. The cumulative 5-year incidence and adjusted risk for all-cause death were not significantly different between the 2 groups (15% vs. 15%, P=0.53; hazard ratio: 1.15, 95% confidence interval: 0.98-1.35, P=0.08). Ad hoc PCI relative to non-ad hoc PCI was associated with neutral risk for myocardial infarction, any coronary revascularization, and bleeding, but was associated with a trend towards lower risk for stroke (hazard ratio: 0.78, 95% confidence interval: 0.60-1.02, P=0.06). CONCLUSIONS Ad hoc PCI in stable CAD patients was associated with at least comparable 5-year clinical outcomes as with non-ad hoc PCI. Considering patients' preference and the cost-saving, the ad hoc PCI strategy might be a safe and attractive option for patients with stable CAD, although the prevalence of ad hoc PCI was low in the current study population.
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Affiliation(s)
- Toshiaki Toyota
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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Puri P, Carroll J, Patterson B. Cost Savings Associated With Implementation of Peer-Reviewed Appropriate Use Criteria for Percutaneous Coronary Interventions. Am J Cardiol 2016; 117:1289-93. [PMID: 26899491 DOI: 10.1016/j.amjcard.2016.01.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 01/22/2016] [Accepted: 01/22/2016] [Indexed: 11/29/2022]
Abstract
Appropriate use criteria (AUC) for coronary revascularization have been developed to provide a practical standard to assess the quality of patient selection for percutaneous coronary interventions (PCI). However, the economic impact of AUC implementation has yet to be quantified. A peer-reviewed AUC process was implemented at UnityPoint Trinity in February 2012. Volumes of PCI cases were measured in 12-month intervals for 2 years after AUC implementation and compared with volumes from the corresponding 12-month intervals in the 2 years preceding implementation of AUC. Hospital reimbursement was averaged based on each year's payer mix and reimbursement contracts. In the 2 years preceding AUC implementation, PCI volumes were similar (1,414 in 2010 and 1,411 in 2011). After AUC implementation, volumes of PCI decreased by 17% in both 2012 and 2013. From 2012 to 2013, the relative ratio of elective to acute interventions decreased from 1.36 to 1.02. In the same time frame, the proportion of appropriate PCI significantly increased from 76% to 84% (p <0.001). Total hospital reimbursement for PCI decreased by 36% after AUC implementation. In conclusion, implementation of a peer-reviewed AUC process at the UnityPoint Trinity led to significant cost savings through a large decrease in volume of PCI with concurrent improvement in PCI appropriateness.
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Affiliation(s)
| | - Jennifer Carroll
- Department of Cardiology, UnityPoint Trinity, Rock Island, Illinois
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Kumbhani DJ, Marso SP. Inpatient or Outpatient Status for Elective Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2016; 9:e003699. [DOI: 10.1161/circinterventions.116.003699] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dharam J. Kumbhani
- From the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Steven P. Marso
- From the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
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Rao C, Bongiovanni T, Li X, Gao H, Zhang H, Li J, Zhao Y, Yuan X, Hua K, Hu S, Krumholz HM, Jiang L, Zheng Z. The China Patient-Centred Evaluative Assessment of Cardiac Events (China PEACE)-Prospective Study of 3-Vessel Disease: rationale and design. BMJ Open 2016; 6:e009743. [PMID: 26880670 PMCID: PMC4762131 DOI: 10.1136/bmjopen-2015-009743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 01/12/2016] [Accepted: 01/14/2016] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Complex coronary artery disease (left main and three-vessel disease) carries high risks of adverse events and cost burden. However, in China, little is known about which patients are directed toward which treatment strategies and what outcomes are being achieved. METHODS AND ANALYSIS Using the China PEACE (Patient-centered Evaluative Assessment of Cardiac Events) research network, this prospective study of three-Vessel Disease, the China PEACE-3VD study, has a plan to consecutively register over 4000 patients with a diagnosis of 3VD and/or left-main disease by elective coronary angiography at 24 large cardiovascular centres in China. We centrally conducted medical record abstraction and SYNTAX Score calculation for all registered patients. The sites invited patients to the prospective cohort, and conducted 1-year follow-up on major events, including cardiac events, symptoms, secondary prevention and quality of life. The estimated entire sample size of eligible patients of 4000 was determined based on both feasibility and consideration of adequate statistical precision for describing the treatment decisions, guidelines adherence and appropriateness of treatment for patients with complex coronary artery diseases. The study is designed to investigate patient, clinician and hospital factors associated with each treatment strategy (percutaneous coronary intervention, coronary artery bypass grafting or medical therapy) as well as appropriateness of treatment choice, current guideline compliance and patient-reported outcomes for patients with complex coronary artery disease in large cardiovascular centres in China, as a foundation for enhanced knowledge in the field and to assist quality improvement initiatives. ETHICS AND DISSEMINATION The study protocol was approved by the ethics committee at the China National Center for Cardiovascular Diseases. Findings will be shared with participating hospitals, policymakers and the academic community, to promote quality monitoring, quality improvement and the efficient allocation, and use of coronary revascularisation procedures in China. TRIAL REGISTRATION NUMBER NCT01625312; Pre-results.
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Affiliation(s)
- Chenfei Rao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Tasce Bongiovanni
- Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Huawei Gao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Heng Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yan Zhao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xin Yuan
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Kun Hua
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shengshou Hu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Harlan M Krumholz
- Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Lixin Jiang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Shuvy M, Guo H, Wijeysundera HC, Feindel CM, Cohen EA, Austin PC, Kingsbury K, Natarajan MK, Tu JV, Ko DT. Medical Therapy and Coronary Revascularization for Patients With Stable Coronary Artery Disease and Unclassified Appropriateness Score. Am J Cardiol 2015; 116:1815-21. [PMID: 26611121 DOI: 10.1016/j.amjcard.2015.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 09/19/2015] [Accepted: 09/19/2015] [Indexed: 10/23/2022]
Abstract
Although the appropriate use criteria incorporate common clinical scenarios for coronary revascularization, a significant proportion of patients with stable coronary artery disease (CAD) cannot be assigned an appropriateness score. Our objective was to characterize these patients and to evaluate whether coronary revascularization is associated with improved outcomes. A population-based cohort of patients aged ≥66 years, who underwent cardiac catheterization in Ontario, Canada, were included. Clinical characteristics were compared between patients with and without an appropriateness score. Clinical outcomes between coronary revascularization and medical therapy in patients with unclassified appropriateness score were compared using the inverse probability of treatment-weighted propensity method for confounder adjustment. Of the 19,228 patients with stable CAD, 11.2% (2,153 patients) were not assigned to an appropriateness score, mostly (92.9%) because of a lack of ischemic evaluation or a noninterpretable test. These patients were older, had higher rate of severe angina, and had more medical co-morbidities compared to patients with an appropriateness score. The 2-year rate of death or myocardial infarction in patients with unclassified appropriateness score was 15.3% in the revascularization group versus 20.7% in the medical therapy group. After propensity weighting, revascularization was associated with significantly lower hazard ratio (0.70; 95% confidence interval 0.61 to 0.79) for death or myocardial infarction compared with medical therapy. In conclusion, in patients aged ≥66 years with stable CAD and unclassified appropriateness score, revascularization is associated with improved outcomes.
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Desai NR, Parzynski CS, Krumholz HM, Minges KE, Messenger JC, Nallamothu BK, Curtis JP. Patterns of Institutional Review of Percutaneous Coronary Intervention Appropriateness and the Effect on Quality of Care and Clinical Outcomes. JAMA Intern Med 2015; 175:1988-90. [PMID: 26551259 PMCID: PMC5584388 DOI: 10.1001/jamainternmed.2015.6217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Nihar R Desai
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut2Center for Outcomes Research and Evaluation, Yale-New Haven Health Services Corporation, New Haven, Connecticut
| | - Craig S Parzynski
- Center for Outcomes Research and Evaluation, Yale-New Haven Health Services Corporation, New Haven, Connecticut
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut2Center for Outcomes Research and Evaluation, Yale-New Haven Health Services Corporation, New Haven, Connecticut
| | - Karl E Minges
- Center for Outcomes Research and Evaluation, Yale-New Haven Health Services Corporation, New Haven, Connecticut
| | - John C Messenger
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Diseases, University of Michigan, Ann Arbor5Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut2Center for Outcomes Research and Evaluation, Yale-New Haven Health Services Corporation, New Haven, Connecticut
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Desai NR, Bradley SM, Parzynski CS, Nallamothu BK, Chan PS, Spertus JA, Patel MR, Ader J, Soufer A, Krumholz HM, Curtis JP. Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection, and Appropriateness of Percutaneous Coronary Intervention. JAMA 2015; 314:2045-53. [PMID: 26551163 PMCID: PMC5459470 DOI: 10.1001/jama.2015.13764] [Citation(s) in RCA: 181] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
IMPORTANCE Appropriate Use Criteria for Coronary Revascularization were developed to critically evaluate and improve patient selection for percutaneous coronary intervention (PCI). National trends in the appropriateness of PCI have not been examined. OBJECTIVE To examine trends in PCI utilization, patient selection, and procedural appropriateness following the introduction of Appropriate Use Criteria. DESIGN, SETTING, AND PARTICIPANTS Multicenter, longitudinal, cross-sectional analysis of patients undergoing PCI between July 1, 2009, and December 31, 2014, at hospitals continuously participating in the National Cardiovascular Data Registry CathPCI registry over the study period. MAIN OUTCOMES AND MEASURES Proportion of nonacute PCIs classified as inappropriate at the patient and hospital level using the 2012 Appropriate Use Criteria for Coronary Revascularization. RESULTS A total of 2.7 million PCI procedures from 766 hospitals were included. Annual PCI volume of acute indications was consistent over the study period (377,540 in 2010; 374,543 in 2014), but the volume of nonacute PCIs decreased from 89,704 in 2010 to 59,375 in 2014. Among patients undergoing nonacute PCI, there were significant increases in angina severity (Canadian Cardiovascular Society grade III/IV angina, 15.8% in 2010 and 38.4% in 2014), use of antianginal medications prior to PCI (at least 2 antianginal medications, 22.3% in 2010 and 35.1% in 2014), and high-risk findings on noninvasive testing (22.2% in 2010 and 33.2% in 2014) (P < .001 for all), but only modest increases in multivessel coronary artery disease (43.7% in 2010 and 47.5% in 2014, P < .001). The proportion of nonacute PCIs classified as inappropriate decreased from 26.2% (95% CI, 25.8%-26.6%) to 13.3% (95% CI, 13.1%-13.6%), and the absolute number of inappropriate PCIs decreased from 21,781 to 7921. Hospital-level variation in the proportion of PCIs classified as inappropriate persisted over the study period (median, 12.6% [interquartile range, 5.9%-22.9%] in 2014). CONCLUSIONS AND RELEVANCE Since the publication of the Appropriate Use Criteria for Coronary Revascularization in 2009, there have been significant reductions in the volume of nonacute PCI. The proportion of nonacute PCIs classified as inappropriate has declined, although hospital-level variation in inappropriate PCI persists.
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Affiliation(s)
- Nihar R Desai
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut2Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Steven M Bradley
- Division of Cardiology, Department of Medicine, VA Eastern Colorado Health Care System, Denver4Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora
| | - Craig S Parzynski
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | | | - Paul S Chan
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri7Department of Medicine, University of Missouri-Kansas City
| | - John A Spertus
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri7Department of Medicine, University of Missouri-Kansas City
| | - Manesh R Patel
- Division of Cardiovascular Medicine, Duke Heart Center, Duke Clinical Research Institute, Duke Medicine, Durham, North Carolina
| | - Jeremy Ader
- Yale School of Medicine, New Haven, Connecticut
| | - Aaron Soufer
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut2Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut2Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
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Thomas MP, Parzynski CS, Curtis JP, Seth M, Nallamothu BK, Chan PS, Spertus JA, Patel MR, Bradley SM, Gurm HS. Percutaneous Coronary Intervention Utilization and Appropriateness across the United States. PLoS One 2015; 10:e0138251. [PMID: 26379053 PMCID: PMC4575022 DOI: 10.1371/journal.pone.0138251] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/26/2015] [Indexed: 11/19/2022] Open
Abstract
Background Substantial geographic variation exists in percutaneous coronary intervention (PCI) use across the United States. It is unclear the extent to which high PCI utilization can be explained by PCI for inappropriate indications. The objective of this study was to examine the relationship between PCI rates across regional healthcare markets utilizing hospital referral regions (HRRs) and PCI appropriateness. Methods The number of PCI procedures in each HRR was obtained from the 2010 100% Medicare limited data set. HRRs were divided into quintiles of PCI utilization with increasing rates of utilization progressing to quintile 5. NCDR CathPCI Registry® data were used to evaluate patient characteristics, appropriate use criteria (AUC), and outcomes across the HRR quintiles defined by PCI utilization with the study population restricted to HRRs where ≥ 80% of the PCIs were performed at institutions participating in the registry. PCI appropriateness was defined using 2012 AUC by the American College of Cardiology (ACC)/American Heart Association (AHA)/The Society for Cardiovascular Angiography and Interventions (SCAI). Results Our study cohort comprised of 380,981 patients treated at 178 HRRs. Mean PCI rates per 1,000 increased from 4.6 in Quintile 1 to 10.8 in Quintile 5. The proportion of non-acute PCIs was 27.7% in Quintile 1 increasing to 30.7% in Quintile 5. Significant variation (p < 0.001) existed across the quintiles in the categorization of appropriateness across HRRs of utilization with more appropriate PCI in lower utilization areas (Appropriate: Q1, 76.53%, Q2, 75.326%, Q3, 75.23%, Q4, 73.95%, Q5, 72.768%; Inappropriate: Q1 3.92%, Q2 4.23%, Q3 4.32%, Q4 4.35%, Q5 4.05%; Uncertain: Q1 8.29%, Q2 8.84%, Q3 8.08%, Q4 9.01%, Q5 8.93%; Not Mappable: Q1 11.26%, Q2 11.67%, Q3 12.37%, Q4 12.69%, Q5 14.34%). There was no difference in risk-adjusted mortality across quintiles of PCI utilization. Conclusions Geographic regions with lower PCI rates have a higher proportion of PCIs performed for appropriate indications. Areas that perform more PCIs also appear to perform more elective PCI and many could not be mapped by the AUC.
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Affiliation(s)
- Michael P. Thomas
- Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
- Cardiovascular Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Craig S. Parzynski
- Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Jeptha P. Curtis
- Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Milan Seth
- Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Brahmajee K. Nallamothu
- Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
- Cardiovascular Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
| | - Paul S. Chan
- Saint Luke’s Mid America Heart and Vascular Institute, Kansas City, Missouri, United States of America
| | - John A. Spertus
- Saint Luke’s Mid America Heart and Vascular Institute, Kansas City, Missouri, United States of America
| | - Manesh R. Patel
- Duke Clinical Research Institute, Durham, North Carolina, United States of America
| | - Steven M. Bradley
- Cardiovascular Medicine, University of Colorado and VA Eastern Colorado Healthcare System, Denver, Colorado, United States of America
| | - Hitinder S. Gurm
- Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
- Cardiovascular Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
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Real-World Use and Appropriateness of Coronary Interventions for Chronic Total Occlusion (from a Japanese Multicenter Registry). Am J Cardiol 2015; 116:858-64. [PMID: 26183792 DOI: 10.1016/j.amjcard.2015.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 06/10/2015] [Accepted: 06/10/2015] [Indexed: 12/14/2022]
Abstract
Little is known about the outcomes and indications of chronic total occlusion percutaneous coronary intervention (CTO-PCI), other than in high-volume centers. We sought to provide a real-world overview of the clinical outcomes and appropriateness of PCI for CTO. The analysis included 4,950 consecutive PCIs for nonacute indications registered in the multicenter Japanese PCI registry in collaboration with the US National Cardiovascular Data Registry (Cath-PCI). Data included demographics, clinical outcomes (procedural success and complication rates), and the indication appropriateness, based on the 2012 appropriate use criteria for revascularization. The overall procedural success and major adverse cardiac event rates of 501 cases with CTO-PCI (10.1%) were 76% and 3.2%, respectively. Based on the criteria, mapping failures occurred in 2,521 procedures; the remaining 2,429 PCIs were successfully mapped. The CTO-PCIs were performed for more appropriate indications than PCIs for lesions without CTO. The rate of inappropriate indications was significantly lower in CTO-PCIs than in non-CTO-PCIs (23.0% vs 31.4%, p = 0.04). Only 17% of CTO-PCIs were directly assigned to CTO-specific scenarios because such scenarios are only intended for "Lone" CTO; the rest of the CTO-PCI cases were secondarily mapped to non-CTO-specific scenarios. In conclusion, as many as 10% of the elective PCIs were performed for CTO lesions in a contemporary multicenter Japanese PCI registry; CTO-PCI was associated with lower procedural success and higher complication rates than non-CTO-PCI. Its indication was relatively appropriate; however, our findings emphasize the need for more rigorous evaluation in terms of the present insufficient CTO-related clinical scenarios.
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Validation of the appropriate use criteria for percutaneous coronary intervention in patients with stable coronary artery disease (from the COURAGE trial). Am J Cardiol 2015; 116:167-73. [PMID: 25960375 DOI: 10.1016/j.amjcard.2015.03.057] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 03/31/2015] [Accepted: 03/31/2015] [Indexed: 11/22/2022]
Abstract
Establishing the validity of appropriate use criteria (AUC) for percutaneous coronary intervention (PCI) in the setting of stable ischemic heart disease can support their adoption for quality improvement. We conducted a post hoc analysis of 2,287 Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial patients with stable ischemic heart disease randomized to PCI with optimal medical therapy (OMT) or OMT alone. Within appropriateness categories, we compared rates of death, myocardial infarction, revascularization subsequent to initial therapy, and angina-specific health status as determined by the Seattle Angina Questionnaire in patients randomized to PCI + OMT to those randomized to OMT alone. A total of 1,987 patients (87.9%) were mapped to the 2012 publication of the AUC, with 1,334 (67.1%) classified as appropriate, 551 (27.7%) uncertain, and 102 (5.1%) as inappropriate. There were no significant differences between PCI and OMT alone in the rate of mortality and myocardial infarction by appropriateness classification. Rates of revascularization were significantly lower in patients initially receiving PCI + OMT who were classified as appropriate (hazard ratio 0.65; 95% confidence interval 0.53 to 0.80; p <0.001) or uncertain (hazard ratio 0.49; 95% confidence interval 0.32 to 0.76; p = 0.001). Furthermore, among patients classified as appropriate by the AUC, Seattle Angina Questionnaire scores at 1 month were better in the PCI-treated group compared with the medical therapy group (80 ± 23 vs 75 ± 24 for angina frequency, 73 ± 24 vs 68 ± 24 for physical limitations, and 68 ± 23 vs 60 ± 24 for quality of life; all p <0.01), with differences generally persisting through 12 months. In contrast, health status scores were similar throughout the first year of follow-up in PCI + OMT patients compared with OMT alone in patients classified as uncertain or inappropriate. In conclusion, these findings support the validity of the AUC in efforts to improve health care quality through optimal use of PCI.
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Inohara T, Kohsaka S, Miyata H, Ueda I, Ishikawa S, Ohki T, Nishi Y, Hayashida K, Maekawa Y, Kawamura A, Higashi T, Fukuda K. Appropriateness ratings of percutaneous coronary intervention in Japan and its association with the trend of noninvasive testing. JACC Cardiovasc Interv 2015; 7:1000-9. [PMID: 25234672 DOI: 10.1016/j.jcin.2014.06.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 06/16/2014] [Accepted: 06/18/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the appropriateness of percutaneous coronary intervention (PCI) in Japan and clarify the association between trends of pre-procedural noninvasive testing and changes in appropriateness ratings. BACKGROUND Although PCI appropriateness criteria are widely used for quality-of-care improvement, they have not been validated internationally. Furthermore, the correlation of appropriateness ratings with implementation of newly developed noninvasive testing is unclear. METHODS We assigned an appropriateness rating to 11,258 consecutive PCIs registered in the Japanese Cardiovascular Database according to appropriateness use criteria developed in 2009 (AUC/2009) and the 2012 revised version (AUC/2012). Trends of pre-procedural noninvasive testing and appropriateness ratings were plotted; logistic regression was performed to identify inappropriate PCI predictors. RESULTS In nonacute settings, 15% of PCIs were rated inappropriate under AUC/2009, and this percent increased to 30.7% under AUC/2012 criteria. This was mostly because of the focused update of AUC, in which the patients were newly classified as inappropriate if they lacked proximal left anterior descending lesions and did not undergo pre-procedural noninvasive testing. However, these cases were simply not rated under AUC/2009. The amount of inappropriate PCIs increased over 5 years, proportional to the increase in coronary computed tomography angiography use. Use of coronary computed tomography angiography was independently associated with inappropriate PCIs (odds ratio: 1.33; p = 0.027). CONCLUSIONS In a multicenter, Japanese PCI registry, approximately one-sixth of nonacute PCIs were rated as inappropriate under AUC/2009, increasing to approximately one-third under the revised AUC/2012. This significant gap may reflect a needed shift in appropriateness recognition of methods for noninvasive pre-procedural evaluation of coronary artery disease.
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Affiliation(s)
- Taku Inohara
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, The University of Tokyo, Tokyo, Japan
| | - Ikuko Ueda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shiro Ishikawa
- Department of Cardiology, Saitama City Hospital, Saitama, Japan
| | - Takahiro Ohki
- Department of Cardiology, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Japan
| | - Yutaro Nishi
- Cardiovascular Center, St. Luke's International Hospital, Tokyo, Japan
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yuichiro Maekawa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Akio Kawamura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Takahiro Higashi
- Division of Cancer Health Services Research, Center for Cancer Control and Information Services, The National Cancer Center, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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29
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Hung OY, Samady H, Anderson HV. Appropriate use criteria: lessons from Japan. JACC Cardiovasc Interv 2015; 7:1010-3. [PMID: 25234673 DOI: 10.1016/j.jcin.2014.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 06/19/2014] [Indexed: 11/18/2022]
Affiliation(s)
- Olivia Y Hung
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Habib Samady
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - H Vernon Anderson
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at Houston, Houston, Texas.
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Bradley SM, Bohn CM, Malenka DJ, Graham MM, Bryson CL, McCabe JM, Curtis JP, Lambert-Kerzner A, Maynard C. Temporal Trends in Percutaneous Coronary Intervention Appropriateness: Insights From the Clinical Outcomes Assessment Program. Circulation 2015; 132:20-6. [PMID: 26022910 DOI: 10.1161/circulationaha.114.015156] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 04/27/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND It is unknown whether the appropriate use of percutaneous coronary intervention (PCI) has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the use of PCI. METHODS AND RESULTS We applied appropriate use criteria to determine the appropriateness of all 51 872 PCI performed in Washington State from 2010 through 2013. We evaluated the number of PCIs performed from 2006 through 2013 to provide a comparator period that preceded statewide appropriateness assessment beginning in 2010. Between 2010 and 2013, the overall number of PCI decreased by 6.8% (13 267 PCIs in 2010 to 12 193 in 2013) with a 43% decline in the number of PCIs for elective indications (3818 PCIs in 2010 to 2193 PCIs in 2013). The decline in the use of elective PCI was significantly larger after the onset of statewide PCI appropriateness assessment in 2010 (P=0.03). The proportion of elective PCIs classified as appropriate increased from 26% in 2010 to 38% in 2013, whereas the proportion of inappropriate PCIs decreased from 16% to 13% (P<0.001 for trends). Significant improvements in the proportion of inappropriate PCI were limited to the tertile of hospitals with the largest decline in PCIs classified as inappropriate (25% in 2010 to 12% in 2013; P=0.03). CONCLUSIONS In Washington State, the use of PCI for elective indications has decreased over time with concurrent improvements in PCI appropriateness. However, improvements in PCI appropriateness were limited to a minority of hospitals. Understanding processes at these high-performing hospitals may inform efforts to improve PCI appropriateness.
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Affiliation(s)
- Steven M Bradley
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.).
| | - Chad M Bohn
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - David J Malenka
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - Michelle M Graham
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - Chris L Bryson
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - James M McCabe
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - Jeptha P Curtis
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - Anne Lambert-Kerzner
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - Charles Maynard
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
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Appropriateness of coronary interventions in Japan by the US and Japanese standards. Am Heart J 2014; 168:854-61.e11. [PMID: 25458648 DOI: 10.1016/j.ahj.2014.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 08/23/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Appropriateness use criteria (AUC) are widely used to assess quality of care. American professional organizations and Japanese experts have both developed original AUC for percutaneous coronary intervention (PCI). However, rating discrepancies have not been investigated. METHODS Patients registered in the Japanese multicenter PCI registry were analyzed. We assessed the appropriateness of PCI based on both the US and Japanese criteria and compared the ratings. A logistic regression analysis was performed to identify clinical predictors of inappropriate ratings under both standards. RESULTS From a total of 4,950 nonacute, consecutive PCIs, 1,982 and 2,077 procedures could be successfully rated using the US and Japanese criteria, respectively. The major difference between the 2 criteria was the rating of "asymptomatic, low- or intermediate-risk patients, no lesion in the proximal left anterior descending coronary artery (PLAD)"; this scenario was deemed appropriate in the Japanese but not in the US criteria. As a consequence, the rate of inappropriate PCI using the Japanese criteria (5.2%) was substantially lower when compared with the rating using the US criteria (15%). Common clinical variables associated with "inappropriate" PCI were male, multivessel diseases, and lesions in the non-PLAD. Suboptimal antianginal medication was also a significant predictor of inappropriate PCI under the US but not under the Japanese criteria. CONCLUSIONS Significant and clinically relevant rating discrepancies were observed between the US and Japanese criteria-based assessments, owing largely to the ratings of asymptomatic, non-PLAD-related, low- or intermediate-risk cases.
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Bradley SM, Spertus JA, Kennedy KF, Nallamothu BK, Chan PS, Patel MR, Bryson CL, Malenka DJ, Rumsfeld JS. Patient selection for diagnostic coronary angiography and hospital-level percutaneous coronary intervention appropriateness: insights from the National Cardiovascular Data Registry. JAMA Intern Med 2014; 174:1630-9. [PMID: 25156821 PMCID: PMC4276416 DOI: 10.1001/jamainternmed.2014.3904] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
IMPORTANCE Diagnostic coronary angiography in asymptomatic patients may lead to inappropriate percutaneous coronary intervention (PCI) due to a diagnostic-therapeutic cascade. Understanding the association between patient selection for coronary angiography and PCI appropriateness may inform strategies to minimize inappropriate procedures. OBJECTIVE To determine if hospitals that frequently perform coronary angiography in asymptomatic patients, a clinical scenario in which the benefit of angiography is less clear, are more likely to perform inappropriate PCI. DESIGN, SETTING, AND PARTICIPANTS Multicenter observational study of 544 hospitals participating in the CathPCI Registry between July 1, 2009, and September 30, 2013. MAIN OUTCOMES AND MEASURES Hospital proportion of asymptomatic patients at diagnostic coronary angiography and hospital rate of inappropriate PCI as defined by 2012 appropriate use criteria for coronary revascularization. RESULTS Of 1 225 562 patients who underwent elective coronary angiography, 308 083 (25.1%) were asymptomatic. The hospital proportion of angiography among asymptomatic patients ranged from 1.0% to 73.6% (median, 24.7%; interquartile range, 15.9%-35.9%). By hospital quartile of asymptomatic patients at angiography, hospitals with higher rates of asymptomatic patients at angiography had higher median rates of inappropriate PCI (14.8% vs 20.2% vs 24.0 vs 29.4% from lowest to highest quartile, P < .001 for trend). This outcome was attributable to more frequent use of inappropriate PCI in asymptomatic patients at hospitals with higher rates of angiography in asymptomatic patients (5.4% vs 9.9% vs 14.7% vs 21.6% from lowest to highest quartile, P < .001 for trend). Hospitals with higher rates of asymptomatic patients at angiography also had lower rates of appropriate PCI (38.7% vs 33.0% vs 32.3% vs 32.9% from lowest to highest quartile, P < .001 for trend). CONCLUSIONS AND RELEVANCE In a national sample of hospitals, performance of coronary angiography in asymptomatic patients was associated with higher rates of inappropriate PCI and lower rates of appropriate PCI. Improving preprocedural risk stratification and thresholds for coronary angiography may be one strategy to improve the appropriateness of PCI.
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Affiliation(s)
- Steven M Bradley
- Veterans Affairs Eastern Colorado Health Care System, Denver2University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora3Colorado Cardiovascular Outcomes Research Consortium, Denver
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City
| | | | - Paul S Chan
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City
| | | | | | | | - John S Rumsfeld
- Veterans Affairs Eastern Colorado Health Care System, Denver2University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora3Colorado Cardiovascular Outcomes Research Consortium, Denver
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Popova YV, Posnenkova OM, Kiselev AR, Gridnev VI, Dovgalevsky PY. IMPLEMENTATION OF EVIDENCE-BASED CLINICAL-AND-MORPHOLOGICAL APPROPRIATE USE CRITERIA FOR CORONARY REVASCULARIZATION IN PATIENTS WITH ACUTE CORONARY SYNDROME IN RUSSIA. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2014. [DOI: 10.15829/1728-8800-2014-2-24-28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Aim. To study possibility of using the evidence-based clinical-andmorphological appropriate use criteria for percutaneous coronary interventions (PCIs) for expert evaluation of high-technology procedures implementation in patients with acute coronary syndrome (ACS) in Russia.Materials and methods. The appropriateness of performed PCI was assessed in patients with ACS, underwent coronary revascularization. The potential need in PCI was determined in ACS patients refused from coronary revascularization. Assessment was performed with the help of ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update (ACCF 2012). Data from 65,912 ACS patients, containing in Russian ACS Registry (2010–2011) were examined.Results. ACCF 2012 criteria allow to assess the clinical appropriateness of PCI in 79.2% of patients underwent coronary revascularization and to determine the potential need in PCI in 80.6% of patients, refrained from coronary revascularization. Among ACS patients underwent PCI (n=9147), intervention was appropriate in 68.9% of cases. Inappropriate PCI was revealed in 4.6% of cases. Among patients refrained from PCI (n=56765), coronary revascularization was potentially appropriate in 57.9% of cases.Conclusion. ACCF 2012 clinical-and-morphological criteria allow to judge on appropriateness of performed PCI and to evaluate the potential need in PCI among the most part of Russian ACS patients. In present study coronary revascularization was appropriate in the majority of ACS patients. It was shown possible to use the evidence-based clinical-andmorphological criteria for expert evaluation of high-technology procedures implementation in Russian ACS patients.
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Affiliation(s)
- Yu. V. Popova
- Saratov Research Institute of Cardiology, Saratov, Russia
| | | | - A. R. Kiselev
- Saratov Research Institute of Cardiology, Saratov, Russia
| | - V. I. Gridnev
- Saratov Research Institute of Cardiology, Saratov, Russia
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Faxon DP. Variability in the Use of Invasive Services. Circ Cardiovasc Interv 2014; 7:133-5. [DOI: 10.1161/circinterventions.114.001477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David P. Faxon
- From the Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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Hannan EL, Samadashvili Z, Cozzens K, Walford G, Holmes DR, Jacobs AK, Stamato NJ, Venditti FJ, Sharma S, King SB. Appropriateness of Diagnostic Catheterization for Suspected Coronary Artery Disease in New York State. Circ Cardiovasc Interv 2014; 7:19-27. [DOI: 10.1161/circinterventions.113.000741] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Edward L. Hannan
- From the University at Albany, State University of New York (E.L.H., Z.S., K.C.); Johns Hopkins University, Baltimore, MD (G.W.); Mayo Clinic, Rochester, MN (D.R.H.); Boston Medical Center, MA (A.K.J.); United Health Services, Binghamton, NY (N.J.S.); Albany Medical Center, NY (F.J.V.); Mt. Sinai Medical Center, New York, NY (S.S.); and St. Joseph’s Health System, Atlanta, GA (S.B.K.)
| | - Zaza Samadashvili
- From the University at Albany, State University of New York (E.L.H., Z.S., K.C.); Johns Hopkins University, Baltimore, MD (G.W.); Mayo Clinic, Rochester, MN (D.R.H.); Boston Medical Center, MA (A.K.J.); United Health Services, Binghamton, NY (N.J.S.); Albany Medical Center, NY (F.J.V.); Mt. Sinai Medical Center, New York, NY (S.S.); and St. Joseph’s Health System, Atlanta, GA (S.B.K.)
| | - Kimberly Cozzens
- From the University at Albany, State University of New York (E.L.H., Z.S., K.C.); Johns Hopkins University, Baltimore, MD (G.W.); Mayo Clinic, Rochester, MN (D.R.H.); Boston Medical Center, MA (A.K.J.); United Health Services, Binghamton, NY (N.J.S.); Albany Medical Center, NY (F.J.V.); Mt. Sinai Medical Center, New York, NY (S.S.); and St. Joseph’s Health System, Atlanta, GA (S.B.K.)
| | - Gary Walford
- From the University at Albany, State University of New York (E.L.H., Z.S., K.C.); Johns Hopkins University, Baltimore, MD (G.W.); Mayo Clinic, Rochester, MN (D.R.H.); Boston Medical Center, MA (A.K.J.); United Health Services, Binghamton, NY (N.J.S.); Albany Medical Center, NY (F.J.V.); Mt. Sinai Medical Center, New York, NY (S.S.); and St. Joseph’s Health System, Atlanta, GA (S.B.K.)
| | - David R. Holmes
- From the University at Albany, State University of New York (E.L.H., Z.S., K.C.); Johns Hopkins University, Baltimore, MD (G.W.); Mayo Clinic, Rochester, MN (D.R.H.); Boston Medical Center, MA (A.K.J.); United Health Services, Binghamton, NY (N.J.S.); Albany Medical Center, NY (F.J.V.); Mt. Sinai Medical Center, New York, NY (S.S.); and St. Joseph’s Health System, Atlanta, GA (S.B.K.)
| | - Alice K. Jacobs
- From the University at Albany, State University of New York (E.L.H., Z.S., K.C.); Johns Hopkins University, Baltimore, MD (G.W.); Mayo Clinic, Rochester, MN (D.R.H.); Boston Medical Center, MA (A.K.J.); United Health Services, Binghamton, NY (N.J.S.); Albany Medical Center, NY (F.J.V.); Mt. Sinai Medical Center, New York, NY (S.S.); and St. Joseph’s Health System, Atlanta, GA (S.B.K.)
| | - Nicholas J. Stamato
- From the University at Albany, State University of New York (E.L.H., Z.S., K.C.); Johns Hopkins University, Baltimore, MD (G.W.); Mayo Clinic, Rochester, MN (D.R.H.); Boston Medical Center, MA (A.K.J.); United Health Services, Binghamton, NY (N.J.S.); Albany Medical Center, NY (F.J.V.); Mt. Sinai Medical Center, New York, NY (S.S.); and St. Joseph’s Health System, Atlanta, GA (S.B.K.)
| | - Ferdinand J. Venditti
- From the University at Albany, State University of New York (E.L.H., Z.S., K.C.); Johns Hopkins University, Baltimore, MD (G.W.); Mayo Clinic, Rochester, MN (D.R.H.); Boston Medical Center, MA (A.K.J.); United Health Services, Binghamton, NY (N.J.S.); Albany Medical Center, NY (F.J.V.); Mt. Sinai Medical Center, New York, NY (S.S.); and St. Joseph’s Health System, Atlanta, GA (S.B.K.)
| | - Samin Sharma
- From the University at Albany, State University of New York (E.L.H., Z.S., K.C.); Johns Hopkins University, Baltimore, MD (G.W.); Mayo Clinic, Rochester, MN (D.R.H.); Boston Medical Center, MA (A.K.J.); United Health Services, Binghamton, NY (N.J.S.); Albany Medical Center, NY (F.J.V.); Mt. Sinai Medical Center, New York, NY (S.S.); and St. Joseph’s Health System, Atlanta, GA (S.B.K.)
| | - Spencer B. King
- From the University at Albany, State University of New York (E.L.H., Z.S., K.C.); Johns Hopkins University, Baltimore, MD (G.W.); Mayo Clinic, Rochester, MN (D.R.H.); Boston Medical Center, MA (A.K.J.); United Health Services, Binghamton, NY (N.J.S.); Albany Medical Center, NY (F.J.V.); Mt. Sinai Medical Center, New York, NY (S.S.); and St. Joseph’s Health System, Atlanta, GA (S.B.K.)
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Kiselev AR, Popova YV, Posnenkova OM, Gridnev VI, Dovgalevsky PY. Implementation of percutaneous coronary interventions in patients with acute coronary syndrome in Russia and clinical factors influencing decision making. COR ET VASA 2014. [DOI: 10.1016/j.crvasa.2013.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Bradley SM, Maddox TM, Stanislawski MA, O’Donnell CI, Grunwald GK, Tsai TT, Ho PM, Peterson ED, Rumsfeld JS. Normal Coronary Rates for Elective Angiography in the Veterans Affairs Healthcare System. J Am Coll Cardiol 2014; 63:417-26. [DOI: 10.1016/j.jacc.2013.09.055] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 08/22/2013] [Accepted: 09/10/2013] [Indexed: 11/29/2022]
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Assessment of the new appropriate use criteria for diagnostic catheterization in the detection of coronary artery disease following noninvasive stress testing. Int J Cardiol 2014; 170:371-5. [DOI: 10.1016/j.ijcard.2013.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 10/29/2013] [Accepted: 11/02/2013] [Indexed: 11/22/2022]
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Chan PS, Rao SV, Bhatt DL, Rumsfeld JS, Gurm HS, Nallamothu BK, Cavender MA, Kennedy KF, Spertus JA. Patient and hospital characteristics associated with inappropriate percutaneous coronary interventions. J Am Coll Cardiol 2013; 62:2274-81. [PMID: 24055743 PMCID: PMC3864986 DOI: 10.1016/j.jacc.2013.07.086] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/25/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVES This study sought to examine whether rates of inappropriate percutaneous coronary intervention (PCI) differ by demographic characteristics and insurance status. BACKGROUND Prior studies have found that blacks, women, and those who have public or no health insurance are less likely to undergo PCI. Whether this reflects potential overuse in whites, men, and privately insured patients, in addition to underuse in disadvantaged populations, is unknown. METHODS Within the National Cardiovascular Data Registry CathPCI Registry, we identified 221,254 nonacute PCIs performed between July 2009 and March 2011. The appropriateness of PCI was determined using the Appropriate Use Criteria for coronary revascularization. Multivariable hierarchical regression was used to evaluate the association between patient demographics and insurance status and inappropriate PCI, as defined by the Appropriate Use Criteria. RESULTS Of 211,254 nonacute PCIs, 25,749 (12.2%) were classified as inappropriate. After multivariable adjustment, men (adjusted odd ratio [OR]: 1.08 [95% CI: 1.05 to 1.11]; p < 0.001) and whites (adjusted OR: 1.09 [95% CI: 1.05 to 1.14]; p < 0.001) were more likely to undergo an inappropriate PCI in comparison with women and nonwhites. Compared with privately insured patients, those who had Medicare (adjusted OR: 0.85 [95% CI: 0.83 to 0.88]), other public insurance (adjusted OR: 0.78 [95% CI: 0.73 to 0.83]), and no insurance (adjusted OR: 0.56 [95% CI: 0.50 to 0.61]) were less likely to undergo an inappropriate PCI (p < 0.001). In addition, compared with urban hospitals, those admitted at rural hospitals were less likely to undergo inappropriate PCI, whereas those at suburban hospitals were more likely. CONCLUSIONS For nonacute indications, PCIs categorized as inappropriate were more commonly performed in men, whites, and those who had private insurance. Higher rates of PCI in these patient populations may, in part, be due to procedural overuse.
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Affiliation(s)
- Paul S Chan
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri.
| | - Sunil V Rao
- Duke Clinical Research Institute, Durham, North Carolina
| | - Deepak L Bhatt
- VA Boston Healthcare System, Boston, Massachusetts; Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Brahmajee K Nallamothu
- University of Michigan, Ann Arbor, Michigan; VA Health Services Research and Development Center of Excellence, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Matthew A Cavender
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
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Raza S, Sabik JF, Ellis SG, Houghtaling PL, Rodgers KC, Stockins A, Lytle BW, Blackstone EH. Survival prediction models for coronary intervention: strategic decision support. Ann Thorac Surg 2013; 97:522-8. [PMID: 24021771 DOI: 10.1016/j.athoracsur.2013.06.099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 06/10/2013] [Accepted: 06/20/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND For a given patient with coronary artery disease, it is uncertain which therapy, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), maximizes long-term survival. Hence, we developed survival models for CABG and PCI using bare-metal stents (BMS) or drug-eluting stents (DES), programmed a decision-support tool, and identified its potential usefulness. METHODS From 1995 to 2007, 23,182 patients underwent primary isolated CABG (n=13,114) or first-time PCI with BMS (n=6,964) or DES (n=3,104). Follow-up was 6.3±3.9 years. Survival models were developed independently for each therapy, then all factors appearing in any of the three models were forced into a final model for each. These were programmed into a decision-support tool. Predicted differences in 5-year survival for the same patient among the three therapies were calculated. RESULTS Unadjusted survival was 96%, 86%, and 68% at 1, 5, and 10 years after CABG, 94%, 83%, and 68% after BMS, and 95% and 84% (no 10-year estimate) after DES, respectively. Risk factors for early and mid-term mortality were identified, leading to variable-rich (25 variables) prediction models. Patients most likely to experience a 5-year survival benefit from DES were those undergoing emergency revascularization for acute infarction, and patients most likely to benefit from CABG had extensive coronary artery disease and numerous comorbidities. CONCLUSIONS Detailed prediction models for prognosis after PCI and CABG are useful for developing a clinically relevant, strategic decision-support tool that reveals who may experience a long-term survival benefit from each modality.
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Affiliation(s)
- Sajjad Raza
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Stephen G Ellis
- Department of Cardiovascular Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Penny L Houghtaling
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kerry C Rodgers
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Aleck Stockins
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bruce W Lytle
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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Song Z, Fendrick AM, Safran DG, Landon B, Chernew ME. Global Budgets and Technology-Intensive Medical Services. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2013; 1:15-21. [PMID: 24772385 PMCID: PMC3997740 DOI: 10.1016/j.hjdsi.2013.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND In 2009-2010, Blue Cross Blue Shield of Massachusetts entered into global payment contracts (the Alternative Quality contract, AQC) with 11 provider organizations. We evaluated the impact of the AQC on spending and utilization of several categories of medical technologies, including one considered high value (colonoscopies) and three that include services that may be overused in some situations (cardiovascular, imaging, and orthopedic services). METHODS Approximately 420,000 unique enrollees in 2009 and 180,000 in 2010 were linked to primary care physicians whose organizations joined the AQC. Using three years of pre-intervention data and a large control group, we analyzed changes in utilization and spending associated with the AQC with a propensity-weighted difference-in-differences approach adjusting for enrollee demographics, health status, secular trends, and cost-sharing. RESULTS In the 2009 AQC cohort, total volume of colonoscopies increased 5.2 percent (p=0.04) in the first two years of the contract relative to control. The contract was associated with varied changes in volume for cardiovascular and imaging services, but total spending on cardiovascular services in the first two years decreased by 7.4% (p=0.02) while total spending on imaging services decreased by 6.1% (p<0.001) relative to control. In addition to lower utilization of higher-priced services, these decreases were also attributable to shifting care to lower-priced providers. No effect was found in orthopedics. CONCLUSIONS As one example of a large-scale global payment initiative, the AQC was associated with higher use of colonoscopies. Among several categories of services whose value may be controversial, the contract generally shifted volume to lower-priced facilities or services.
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Affiliation(s)
- Zirui Song
- Department of Health Care Policy, Harvard Medical School
- National Bureau of Economic Research
| | - A. Mark Fendrick
- Departments of Internal Medicine and Health Management & Policy, Center for Value-Based Insurance Design, University of Michigan
| | - Dana Gelb Safran
- Blue Cross Blue Shield of Massachusetts
- Department of Medicine, Tufts University School of Medicine
| | - Bruce Landon
- Department of Health Care Policy, Harvard Medical School
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center
| | - Michael E. Chernew
- Department of Health Care Policy, Harvard Medical School
- National Bureau of Economic Research
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Bikdeli B, Ranasinghe I, Chen R, Gupta A, Lampropulos JF, Kulkarni VT, Mody PS, Dharmarajan K. Most important outcomes research papers on treatment of stable coronary artery disease. Circ Cardiovasc Qual Outcomes 2013; 6:e17-25. [PMID: 23674308 DOI: 10.1161/circoutcomes.113.000310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have been published in the Circulation portfolio. The objective of this series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research related to treatment of stable coronary artery disease (CAD).
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Bradley SM, Spertus JA, Nallamothu BK, Chan PS. Appropriate Use Criteria and percutaneous coronary intervention: measuring patient selection quality. Interv Cardiol 2012. [DOI: 10.2217/ica.12.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Bradley SM, Chan PS, Spertus JA, Kennedy KF, Douglas PS, Patel MR, Anderson HV, Ting HH, Rumsfeld JS, Nallamothu BK. Hospital percutaneous coronary intervention appropriateness and in-hospital procedural outcomes: insights from the NCDR. Circ Cardiovasc Qual Outcomes 2012; 5:290-7. [PMID: 22576845 DOI: 10.1161/circoutcomes.112.966044] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Measurement of hospital quality has traditionally focused on processes of care and postprocedure outcomes. Appropriateness measures for percutaneous coronary intervention (PCI) assess quality as it relates to patient selection and the decision to perform PCI. The association between patient selection for PCI and processes of care and postprocedural outcomes is unknown. METHODS AND RESULTS We included 203 531 patients undergoing nonacute (elective) PCI from 779 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry between July 2009 and April 2011. We examined the association between a hospital's proportion of nonacute PCIs categorized as inappropriate by the 2009 Appropriate Use Criteria (AUC) for Coronary Revascularization and in-hospital mortality, bleeding complications, and use of optimal guideline-directed medical therapy at discharge (ie, aspirin, thienopyridines, and statins). When categorized as hospital tertiles, the range of inappropriate PCI was 0.0% to 8.1% in the lowest tertile, 8.1% to 15.2% in the middle tertile, and 15.2% to 58.6% in the highest tertile. Compared with lowest-tertile hospitals, mortality was not significantly different at middle-tertile (adjusted odds ratio [OR], 0.93; 95% confidence interval [CI], 0.73-1.19) or highest-tertile hospitals (OR, 1.12; 95% CI, 0.88-1.43; P=0.35 for differences between tertiles). Similarly, risk-adjusted bleeding did not vary significantly (middle-tertile OR, 1.13; 95% CI, 1.02-1.16; highest-tertile OR, 1.02; 95% CI, 0.91-1.16; P=0.07 for differences between tertiles) nor did use of optimal medical therapy at discharge (85.3% versus 85.7% versus 85.2%; P=0.58). CONCLUSIONS In a national cohort of nonacute PCIs, a hospital's proportion of inappropriate PCIs was not associated with in-hospital mortality, bleeding, or medical therapy at discharge. This suggests PCI appropriateness measures aspects of hospital PCI quality that are independent of how well the procedure is performed. Therefore, PCI appropriateness and postprocedural outcomes are both important metrics to inform PCI quality.
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Affiliation(s)
- Steven M Bradley
- VA Eastern Colorado Health Care System, Denver, CO 80220-3808, USA.
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