AHA.15: Appropriate use criteria significantly changes patient selection for PCI

Since the American College of Cardiology, American Heart Association (AHA) and other medical societies released appropriate use criteria for coronary revascularization in 2009, the number of nonacute PCIs has significantly decreased, according to a multicenter, longitudinal, cross-sectional analysis. The proportion of nonacute PCIs classified as inappropriate decreased from 26.2 percent in 2010 to 13.3 percent in 2014.

Lead researcher Nihar R. Desai, MD, MPH, of Yale-New Haven Hospital in Connecticut, presented results of the study at the AHA Scientific Sessions on Nov. 9. The findings were simultaneously published online in JAMA.

Desi said the appropriate use criteria were adopted to evaluate and improve patient selection for PCIs. He added that previous studies found up to 1 in 6 PCIs performed for non-acute indications were inappropriate and that performance varied across hospitals.

Desai and his colleagues analyzed data from 2,685,683 PCI procedures performed at 766 hospitals between July 1, 2009, and December 31, 2014. The hospitals all performed at least 10 nonacute PCIs each year and continuously participated in the National Cardiovascular Data Registry CathPCI registry, the largest national registry of diagnostic cardiac catheterization and PCI.

The researchers defined acute PCIs as procedures performed in the setting of an acute coronary syndrome. Of the PCIs in this analysis, 76.3 percent were for acute indications, 14.8 percent were for nonacute indications and 8.9 percent were nonmappable.

From 2010 to 2014, the annual volume of nonacute PCIs decreased 33.8 percent from 89,704 to 59,375, while the annual PCI volume of acute indications decreased only 0.8 percent from 377,540 to 374,543.

During that time period, the proportion of PCIs performed for nonacute indications declined from 16.8 percent to 13.0 percent.

In addition, patients undergoing nonacute PCI in 2014 were significantly more likely to have severe angina, use two or more antianginal medications prior to PCI and have high-risk findings on noninvasive testing compared with 2010.

Further, of the nonacute PCIs performed in 2009, 30.1 percent were considered appropriate, 26.2 percent were considered inappropriate and 43.7 were considered uncertain. In 2014, the corresponding rates were 53.6 percent, 13.3 percent and 33.1 perent.

“There was evidence for substantial variation in performance at the hospital level such that in 2014, the best performing hospitals had less than 6 percent of their nonacute PCIs classified as inappropriate while the worst performing hospitals had more than 23 percent of their nonacute PCIs classified as inappropriate,” Desai said.

Desai mentioned a few study limitations, including that they excluded hospitals that were continuously enrolled in the registry and that all hospitals in the U.S. do not participate in the registry. The researchers also did not address if the appropriate use criteria had introduced new barriers to the performance of medically necessary procedures.

“We cannot determine whether the observed changes and reductions in inappropriate PCI fully reflect improvements in quality of care and patient selection as improved documentation or even possibly intentional upcoding particularly of subjective data elements such as symptom severity may have contributed,” Desai said.