Use of inappropriate PCI procedures declined in recent years

ORLANDO, Fla. — From 2010 to 2014, the annual number of PCI procedures classified as inappropriate declined sharply, according to research presented at the American Heart Association Scientific Sessions.

However, variation in the performance of rarely appropriate stent procedures persisted across U.S. hospitals.

Using data from the National Cardiovascular Data Registry (NCDR) CathPCI Registry, investigators analyzed records from more 2.7 million PCI procedures performed at 766 hospitals from July 2009 to December 2014. The goal was to examine the proportion of nonacute PCI procedures classified as “inappropriate” at the patient and hospital level, based on the 2012 Appropriate Use Criteria for Coronary Revascularization.

The annual volume of PCI procedures for acute or emergent conditions remained stable during the study period, with 377,540 procedures performed in 2010 vs. 374,543 in 2014. However, the annual volume of PCI procedures performed for nonacute or elective reasons declined, from 89,704 in 2010 to 59,375 in 2014.

The proportion of nonacute PCI procedures classified as inappropriate decreased by half, from 26.2% in 2010 to 13.3% in 2014; the absolute number of inappropriate procedures decreased by 64% (21,781 to 7,921).

In other results, among hospitals with the highest initial rates of rarely appropriate procedures, some hospitals reduced their rates to less than 10%, while others maintained rates of more than 30% by the end of the study period, according to a press release.

The researchers also reported increases in angina severity among patients undergoing nonacute PCI; the proportion of patients with Canadian Cardiovascular society grade III/IC angina was 15.8% in 2010 and 38.4% in 2014. Use of antianginal medications before PCI also increased, with at least two antianginal medications used in 22.3% of cases in 2010 compared with 35.1% in 2014.

“The most important finding from our study is that it shows that the practice of interventional cardiology has evolved over a short period of time, and it appears that we are doing a better job of selecting patients who are more likely to benefit from having a stent procedure,” Nihar R. Desai, MD, MPH, assistant professor of medicine at Yale School of Medicine, said in a press release. “At the same time, we’re doing a better job of documenting the reasons why a stent procedure is indicated.”

Robert A. Harrington

In an accompanying editorial to the study, both of which were published in JAMA, Robert A. Harrington, MD, chair of the department of medicine at Stanford University School of Medicine, said the cardiology community has been receptive to using data, evidence and guidelines to inform their practice. The creation of a nationally available quality registry system that allows for “measurement, analysis and feedback” has been an important part of that development, he said. However, he noted that more can be done.

“As noted by Desai et al, not all hospitals that perform angioplasty contribute data to the NCDR,” Harrington wrote. “Second, more emphasis must be placed on achieving interoperability across health care systems.”

To reach these goals, Harrington stressed a need for a national system that provides “real-time clinical support” and makes use of “accumulating data and sophisticated data analytics, including randomization when appropriate. Only at that point will the continuously learning health care system be a reality,” he concluded.

References:

Desai NR, et al. Clinical Science: Special Reports 1. Novel Findings from Next Generation Registries. Presented at: American Heart Association Scientific Sessions; Nov. 7-11, 2015; Orlando, Fla.

Desai NR, et al. JAMA. 2015;doi:10.1001/jama.2015.13764.

Harrington RA. JAMA. 2015;doi:10.1001/jama.2015.15436.

Disclosures: Desai reports receiving a research agreement from Johnson & Johnson through Yale University to develop methods of clinical trial data sharing and receiving funding from CMS to develop and maintain performance measures used for public reporting.