CLINICAL
NEWS JOURNAL WRAP
Kim Eagle, MD, and the editors of ACC.org, present relevant
articles taken from various journals.
The Post-AUC Landscape for PCI
There has been a significant reduction
in the volume of nonacute percutaneous coronary interventions (PCI)
and the proportion of inappropriate
nonacute PCIs has declined since the
publication of appropriate use criteria
(AUC) for coronary revascularization,
according to a recent study in JAMA.
The AUC, published in 2009 by
the ACC and seven other partnering
societies, were developed to evaluate and improve patient selection for
PCI. In 2011, the NCDR CathPCI
Registry® began providing hospitals
with information regarding the appropriateness of PCIs.
The study, led by Nahir R. Desai, MD, MPH, of Yale-New Haven
Hospital, New Haven, CT, examined all
PCIs in the CathPCI registry between
July 1, 2009, and Dec. 31, 2014. PCIs
were classified as acute, nonacute, or
nonmappable, and each mappable PCI
was assigned a rating of procedural appropriateness—appropriate, uncertain,
or inappropriate—based on the 2012
AUC for coronary revascularization.
Over 3.5 million PCIs were
performed at 1,561 hospitals. After
exclusions, researchers included
2,685,683 PCI procedures at 766
hospitals in the study cohort. Of
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these, 76.3% of PCIs were for acute
indications, 14.8% were for nonacute
indications, and 8.9% were nonmappable. The annual volume of PCI
declined from 538,076 in 2010 to
456,507 in 2014. While the volume
of acute PCI was relatively stable
(377.540 to 377,543), the decline in
nonacute and nonmappable PCIs was
significant (89,704 to 59,375 and
70,832 to 22,589, respectively).
The proportion of nonacute PCIs
classified as inappropriate decreased
from 26.2% to 13.3% during the
study period and the absolute number
of inappropriate PCIs decreased from
21,781 to 7,921. The proportion of
nonacute PCIs classified as appropriate increased from 30.1% to 53.6%
and those considered uncertain
decreased from 43.7% to 33.0%. At
hospitals, the proportion of nonacute
PCIs considered inappropriate decreased from 25.8% to 12.6%.
According to the study authors,
four distinct trajectories in changes
in rate of inappropriate PCI between
2011 and 2014 were observed among
hospitals in the highest quartile
for the proportion of nonacute PCI
deemed inappropriate. Hospitals in
groups 1, 2, and 4 had similar base-
line rates of inappropriate PCI, but
the 108 hospitals in group 4 showed
immediate and steady declines in
rates of inappropriate PCI from 43.9%
to 15.5%. The 18 hospitals in group
1 had minimal c hange in the first 2
years but then showed lower rates
of inappropriate PCI in the final 2
years of the study. Group 2, made up
of 50 hospitals, demonstrated steady
but smaller absolute declines in rates
of inappropriate PCI compared with
groups 1 and 4 from 40.9% to 32.3%.
Finally, the 15 hospitals in group 3
had the highest initial rates of inappropriate PCI but also the largest
absolute decline over the study period
from 70.6% to 9.4%. There were no
systematic differences in hospital
characteristic, geographic location,
financial status, or teaching status
across hospital groups.
“This analysis provides detail
about changes in the clinical profiles
of patients undergoing PCI and suggests that the observed reductions
in inappropriate PCI in part reflect
improvements in patient selection
and clinical decision-making as well
as better documentation of the key elements used to determine procedural
appropriateness,” the authors said.
“Trends consistent with improvements in patient selection include the
reduction in nonacute PCI volume
and changes in the clinical profile of
patients undergoing nonacute PCI.”
Meanwhile, the authors caution
that they cannot exclude the possibility
that the decrease in inappropriate PCIs
may be the result of changes in documentation or intentional up-coding,
particularly of subjective data elements
such as symptom severity. However,
they noted they “did not see evidence
that patients were being systematically
shifted from nonacute indications for
PCI. Rather, they noted, the number of
acute PCIs was stable over time, and
“the proportion of patients undergoing
acute PCI reported to have unstable
angina decreased.”
Desai and colleagues also acknowledged that because the cases in their
analysis were all performed after the re-
lease of the AUC, they could not evaluate the impact of the criteria. While the
study’s findings are a description of the
changes in patterns of care during this
period, it is likely that many factors—
including the publication of the COURAGE and BARI 2D trials—influenced
practice during this time as well.
Moving forward, the authors note
that the persistent variation in hospital-level performance of inappropriate
PCI suggests the need for ongoing
performance improvement initiatives
and hospital benchmarking. Identifying the organizational strategies and
structures most strongly associated
with lower rates of inappropriate
PCI is an important area for future
research, they said.
On a related note, a research letter
published at the same time in JAMA
Internal Medicine, also lead by Desai,
examined the patterns of institutional
review of PCI appropriateness since
the AUC was published and found
marked heterogeneity, with almost
one in four hospitals reporting no
review. According to the authors, this
finding suggests that many hospitals
have not prioritized improving their
performance on AUC. There was also
variation in the proportion of rarely
appropriate PCI across institutions,
but there was no association between
hospital review of PCI appropriateness
with procedural appropriateness, use
of guideline-recommended care, or
clinical outcomes.
Of note, hospitals with a higher
volume of nonacute PCI had a lower
proportion or rarely appropriate PCI
across all review frequencies. It is
not clear whether this is a result of
better communication, leadership,
and oversight at higher-volume PCI
centers. The authors conclude that
“there is a pressing need to identify
effective strategies that can be used to
support institutional improvement of
PCI appropriateness.”
Desai NR, Bradley SM, Parzynski CS, et al.
JAMA. 2015;doi:10.1001/jama.2015.13764.
Desai NR, Parzynski CS, Krumholz HM,
et al. JAMA Internal Medicine. 2015;
doi:10.1001/jamainternmed.2015.6217.
January 2016