Rates of inappropriate, elective PCIs decline in New York

Between 2010 and 2014, the rate of inappropriate PCIs and the use of PCI for elective procedures in New York decreased significantly, according to a database analysis. 

More than two-thirds of the hospitals decreased their inappropriateness rates by at least 2.9 percent, and half of hospitals decreased their rates by more than 6.3 percent.

During that time period, the New York State Department of Health shared inappropriate PCI rates with hospitals, published the findings in a peer-reviewed medical journal and recommended denying reimbursement for inappropriate PCIs performed on Medicaid patients.

Lead researcher Edward L. Hannan, PhD, of the University at Albany, and colleagues published their results online in the Journal of the American College of Cardiology on March 6.

In 2009, the American College of Cardiology, American Heart Association and other medical societies released appropriate use criteria for coronary revascularization, according to the researchers. The societies updated the criteria in 2012 and noted that several types of patients undergoing elective PCIs were inappropriate or uncertain.

For this analysis, the researchers used New York’s Percutaneous Coronary Interventions Reporting System, which collects information on patients who undergo PCIs at nonfederal hospitals in the state. They divided the revascularization appropriate use criteria in three categories: acute coronary syndromes (ACS), no ACS/no CABG (referred to as stable PCI patients) and no ACS/prior CABG.

Between 2010 and 2014, the total number of PCIs in New York decreased 12.9 percent, although it increased between 2012 and 2014. Meanwhile, the number of PCIs in Medicaid patients decreased 1 percent during that time period, although it increased 6 percent from 2012 to 2014.

In addition, the number of stable PCI patients decreased from 20,142 in 2010 to 9,261 in 2014, a decline of 54.0 percent. During that same time, the percentage of PCIs performed in stable patients declined from 37 percent to 20 percent.

The rates of inappropriate PCIs decreased from 18.2 percent in 2010 to 10.6 percent in 2014 for all PCI patients, including a decline from 15.3 percent to 6.8 percent in Medicaid patients and a decline from 18.6 percent to 11.2 percent for other patients. All of the decreases were statistically significant.

“Most of this decrease occurred after hospitals were provided their own inappropriateness rates and additional information in early 2012,” the researchers wrote. “With regard to the change in appropriate PCIs performed during the study period, for a select set of higher-risk scenarios, there were more appropriate PCIs in each of the years after the release of inappropriateness rates to hospitals than there were in each of the years before the release. Thus, at least for these scenarios, there was no evidence of a decrease in appropriate PCIs being performed subsequent to initiatives undertaken to reduce inappropriate PCIs.”

The study had a few limitations, according to the researchers, including that the definitions of Canadian Cardiovascular Society class changed in 2012 in the New York registry. They noted that coding changes in the class could have biased results in favor of the later years. They also mentioned that providers were offered incentives to decrease their inappropriateness rates.

“A consequence of this utilization decrease has been the reduction in valuable resources spent by health care payers and the U.S. healthcare system, as well as a reduction in occasional complications that would have occurred with additional PCI procedures,” the researchers wrote. “It remains to be seen whether payers will begin to deny payment on the basis of inappropriateness, but it appears to be unnecessary given that large national and New York decreases in 'inappropriate' PCIs and in PCI use, in general, for stable [coronary artery disease] patients have occurred following national publications and confidential sharing of hospital and operator rates to providers.”