Percutaneous Coronary Intervention Utilization and Appropriateness across the United States (original) (raw)
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Growth in Percutaneous Coronary Intervention Capacity Relative to Population and Disease Prevalence
Journal of the American Heart Association, 2013
Background The access to and growth of percutaneous coronary intervention ( PCI ) has not been fully explored with regard to geographic equity and need. Economic factors and timely access to primary PCI provide the impetus for growth in PCI centers, and this is balanced by volume standards and the benefits of regionalized care. Methods and Results Geospatial and statistical analyses were used to model capacity, growth, and access of PCI hospitals relative to population density and myocardial infarction ( MI ) prevalence at the state level. Longitudinal data were obtained for 2003–2011 from the A merican H ospital A ssociation, the U . S . Census, and the C enters for D isease C ontrol and P revention (CDC) with geographical modeling to map PCI locations. The number of PCI centers has grown 21.2% over the last 8 years, with 39% of all hospitals having interventional cardiology capabilities. During the same time, the US population has grown 8.3%, from 217 million to 235 million, and M...
Percutaneous Coronary Intervention Use in the United States
JACC: Cardiovascular Interventions, 2012
Appropriate utilization of percutaneous coronary intervention (PCI) and medical therapy is deservedly a national healthcare policy priority for the United States. Because PCI is both common and costly, appraisal of appropriateness is warranted. The initial appropriate use criteria (AUC) have been developed for coronary revascularization procedures and investigators recently reported the appropriateness for the approximately 500,000 PCI procedures performed at centers participating in the National Cardiovascular Data Registry. The AUC have broad implications for both healthcare providers and our patients and will be used as the basis for indications, referral patterns, treatment options, physician education, shared decision-making, and reimbursement for years to come. While we acknowledge the importance of thoughtfully assessing appropriateness for all medical procedures including PCI, there are a number of concerns with the current AUC and methods used to report appropriateness that warrant expanded commentary. (J Am Coll Cardiol Intv 2012;5:229-35) © 2012 by the American College of Cardiology Foundation Appropriate use of percutaneous coronary intervention (PCI) and medical therapy is deservedly a national healthcare policy priority. Because PCI is both common (1,2) and costly, appraisal of PCI use is warranted. Thus, when a recent appropriateness use paper was published in the Journal of the American Medical Association (JAMA), it received national attention and brought again to the forefront the possibility of PCI overuse in the United States (3). Following this publication, there was a flurry of national stories focusing on the apparent overuse of PCI (4,5). Often, these national stories link the JAMA paper findings to selected high-profile cases See page 236 where individual operators are under legal investigation for the systematic overuse of PCI (6). As practicing clinical cardiologists, we all must remain committed to delivering high-quality and responsive care to our patients. Clinicians should also strive to offer treatments that minimize the burden of managing a chronic medical condition such as coronary artery disease, whether the burden stems from procedures, office visits, or medical therapy.
Circulation, 2014
The relationship between operator or institutional volume and outcomes among patients undergoing percutaneous coronary interventions (PCI) is unclear. Cross-sectional study based on the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample between 2005 to 2009. Subjects were identified by International Classification of Diseases, 9(th) Revision, Clinical Modification procedure code, 36.06 and 36.07. Annual operator and institutional volumes were calculated using unique identification numbers and then divided into quartiles. Three-level hierarchical multivariate mixed models were created. The primary outcome was in-hospital mortality; secondary outcome was a composite of in-hospital mortality and peri-procedural complications. A total of 457,498 PCIs were identified representing a total of 2,243,209 PCIs performed in the United States during the study period. In-hospital, all-cause mortality was 1.08%, and the overall complication rate was 7.10%. The primary and s...
Circulation. Cardiovascular quality and outcomes, 2014
Whether increasing use of radial access has improved percutaneous coronary intervention outcomes remains unknown. We sought to determine the relationship between increasing facility-level use of transradial percutaneous coronary intervention (TRI) and periprocedural outcomes. Within the National Cardiovascular Data Registry CathPCI Registry, we estimated the risk-adjusted association between hospital category of change in TRI use (during the 3-year period from 2009 to 2012) and trends in access site and overall bleeding, fluoroscopy time, and contrast use among 818 facilities with low baseline TRI use. There were 4 categories of hospital change in TRI use: very low (baseline, 0.2% increasing to 1.8% at the end of 3 years), low (0.9% increasing to 8.9%), moderate (1.6% increasing to 27.2%), and high (1.0% increasing to 45.1%). Risk-adjusted access site bleeding decreased over time for all hospital categories; however, the rate of decline varied across hospital categories (P for inter...
Circulation: Cardiovascular Quality and Outcomes, 2012
Background— Measurement of hospital quality has traditionally focused on processes of care and postprocedure outcomes. Appropriateness measures for percutaneous coronary intervention (PCI) assess quality as it relates to patient selection and the decision to perform PCI. The association between patient selection for PCI and processes of care and postprocedural outcomes is unknown. Methods and Results— We included 203 531 patients undergoing nonacute (elective) PCI from 779 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry between July 2009 and April 2011. We examined the association between a hospital's proportion of nonacute PCIs categorized as inappropriate by the 2009 Appropriate Use Criteria (AUC) for Coronary Revascularization and in-hospital mortality, bleeding complications, and use of optimal guideline-directed medical therapy at discharge (ie, aspirin, thienopyridines, and statins). When categorized as hospital tertiles, the ra...
Circulation. Cardiovascular quality and outcomes, 2018
Assessments of healthcare value have largely focused on measuring outcomes of care at a given level of cost with less attention paid to appropriateness. However, understanding how appropriateness relates to outcomes and costs is essential to determining healthcare value. In a retrospective cohort study design, administrative data from fee-for-service Medicare patients undergoing percutaneous coronary intervention (PCI) in Michigan hospitals between June 30, 2010, and December 31, 2014, were linked with clinical data from a statewide PCI registry to calculate hospital-level measures of (1) appropriate use criteria scores, (2) 90-day risk-standardized readmission and mortality rates, and (3) 90-day risk-standardized episode costs. We then used Spearman correlation coefficients to assess the relationship between these measures. A total of 29 839 PCIs were performed at 33 PCI hospitals during the study period. A total of 13.3% were for ST-segment-elevation myocardial infarction, 25.0% f...
Appropriateness of Percutaneous Coronary Interventions in Washington State
Circulation: Cardiovascular Quality and Outcomes, 2012
Background— In anticipation of applying Appropriate Use Criteria for percutaneous coronary intervention (PCI) quality improvement, we determined the prevalence of appropriate, uncertain, and inappropriate PCIs stratified by indication for all PCIs performed in the state of Washington. Methods and Results— Within the Clinical Outcomes Assessment Program, we assigned appropriateness ratings to all PCIs performed in 2010 in accordance with published Appropriate Use Criteria. Of 13 291 PCIs, we successfully mapped the clinical scenario to the Appropriate Use Criteria in 9924 (75%) cases. Of the 3367 PCIs not classified, common failures to map to the criteria included nonacute PCI without prior noninvasive stress results (n = 1906; 57%) and unstable angina without high-risk features (n = 902; 27%). Of mapped PCIs, 8010 (71%) were for acute indications, with 7887 (98%) rated as appropriate, 39 (<1%) as uncertain, and 84 (1%) as inappropriate. Of 1914 mapped nonacute indications, 847 (4...
Circulation, 2015
Background-Although numerous studies have reported that cardiac rehabilitation (CR) is associated with reduced mortality after myocardial infarction, less is known about its association with mortality after percutaneous coronary intervention. Methods and Results-We performed a retrospective analysis of data from a prospectively collected registry of 2395 consecutive patients who underwent percutaneous coronary intervention in Olmsted County, Minnesota, from 1994 to 2008. The association of CR with all-cause mortality, cardiac mortality, myocardial infarction, or revascularization was assessed with 3 statistical techniques: propensity score-matched analysis (nϭ1438), propensity score stratification (nϭ2351), and regression adjustment with propensity score in a 3-month landmark analysis (nϭ2009). During a median follow-up of 6.3 years, 503 deaths (199 cardiac), 394 myocardial infarctions, and 755 revascularization procedures occurred in the study subjects. Participation in CR, noted in 40% (964 of 2395) of the cohort, was associated with a significant decrease in all-cause mortality by all 3 statistical techniques (hazard ratio, 0.53 to 0.55; PϽ0.001). A trend toward decreased cardiac mortality was also observed in CR participants; however, no effect was observed for subsequent myocardial infarction or revascularization. The association between CR participation and reduced mortality rates was similar for men and women, for older and younger patients, and for patients undergoing elective or nonelective percutaneous coronary intervention. Conclusion-We found that CR participation after percutaneous coronary intervention was associated with a significant reduction in mortality rates. These findings add support to published clinical practice guidelines, performance measures, and insurance coverage policies that recommend CR for patients after percutaneous coronary intervention. (Circulation. 2011;123:2344-2352.) The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.110.983536/DC1.