Transparency helps reduce inappropriate PCI rates

In early 2012, hospitals in New York received reports from the state on their inappropriate PCI rates. The state later published the rates in a medical journal and recommended that payers deny reimbursement for inappropriate PCIs in Medicaid patients.

The transparency initiative apparently worked, at least according to a recent analysis published in the Journal of the American College of Cardiology.

In New York, the rate of inappropriate PCIs in New York decreased from 18.2 percent in 2010 to 10.6 percent in 2014. During that time period, the rate of inappropriate PCIs declined from 15.3 percent to 6.8 percent for Medicaid patients and from 18.6 percent to 11.2 percent for other patients.

Meanwhile, the number of inappropriate PCIs in patients with no acute coronary syndromes or no prior CABG decreased 69 percent, including a 75 percent decline in Medicaid patients.

For the study, the researchers used appropriate use criteria (AUC) for coronary revascularization that the American College of College, American Heart Association and other medical societies published in 2012. They analyzed all 58 nonfederal hospitals in New York that performed PCIs between 2010 and 2014.

More than two-third of the hospitals decreased their inappropriateness rates by at least 2.9 percent, while one-half of hospitals decreased their inappropriateness rates by at least 2.9 percent by more than 6.3 percent, according to the researchers.

In addition, the number of PCI patients defined as stable decreased by 54 percent from 2010 to 2014, including a 52 percent decrease in Medicaid patients. During that time period, the percentage of PCIs performed in stable patients declined from 37 percent to 20 percent.

Although the state of New York’s decision to release findings on inappropriate PCIs likely played a role in the declines, the researchers noted that it could also be due to the 2009 release of the AUC. After that document was published, there were national studies of inappropriateness rates in the National Cardiovascular Data Registry (NCDR), according to the researchers.

They mentioned that inappropriateness rates in NDCR decreased 50 percent from 2010 to 2014, which was a higher rate of decline than in New York. However, the decrease in the volume of PCIs for stable coronary artery disease was higher in New York than it was in the NCDR.

The researchers also cited a few limitations of the study, including that the definitions of Canadian Cardiovascular Society class changed in 2012 in the New York registry. Providers were also incentivized to decrease their inappropriateness rates by upcoding patient severity of illness instead of improving patient selection. Still, informing hospitals about their inappropriateness rates seems to have significantly changed practice.

“The success in using AUC to inform evidence-based medicine by professional societies and policy makers can serve as a model for improving the cost effectiveness of other costly health care services,” the researchers wrote. “In general, this approach can serve as an aid to providers in an era when payment will depend on health care outcomes rather than on the services provided. It can also serve as a model for payers and govern- mental agencies in their goal of assuring that procedures and other services will be as cost effective as possible.”