Abstract 7: Appropriateness of Percutaneous Coronary Interventions in Washington State

Abstract

Background. The use of percutaneous coronary intervention (PCI) has increased dramatically in the past decade despite uncertainty regarding the appropriateness of these procedures. Methods. Within the Clinical Outcomes Assessment Program (COAP), a quality-improvement initiative that captures all revascularization procedures performed in Washington State, we assessed the appropriateness of PCI performed between June 2009 and September 2010 in accordance with published Appropriate Use Criteria. We report the appropriateness of PCI stratified by acute (acute myocardial infarction or unstable angina with high-risk features) or non-acute (stable angina) coronary presentation. Results. Of 12,528 PCI performed during the study period, we successfully mapped the PCI indication to the Appropriate Use Criteria in 9,025 (72%) of cases. Of the 3,521 PCI not classified, common failures to map to the criteria included acute PCI of multiple lesions without evidence of shock (n=517, 14.7%), unstable angina without high-risk features (n=918, 26.1%), or non-acute PCI without preprocedural non-invasive stress results (n=2,049, 58.2%). Of mapped PCI, 7,031 (77.9%) were for acute indications with 6,921 (98.4%) rated as “appropriate”, 40 (0.6%) as “uncertain”, and 70 (1.0%) as “inappropriate”. Of 1,987 non-acute coronary presentations, 788 (39.7%) were rated as appropriate, 812 (40.9%) as uncertain, and 387 (19.5%) as inappropriate (Table). Assuming non-acute PCI with missing data on non-invasive stress test were performed in the setting of high-risk non-invasive stress testing, 387 (9.8%) PCI were inappropriate. Conclusion. In a complete cohort of PCI performed in Washington State, 1.0% of PCI for acute indications and 9.8% of PCI for non-acute indications were classified as inappropriate after assumptions to maximize appropriateness. These findings suggest an opportunity to improve the selection of patients undergoing PCI to maximize anticipated benefit. TABLE 1 Appropriateness of PCI in Washington State PCI Indication Total Cases Appropriateness Rating by Indication, n (%) Appropriate Uncertain Inappropriate All PCI 9018 7708 (85.4) 853 (9.5) 464 (4.7) Acute presentation 7031 6921 (98.4) 40 (0.6) 70 (1.0) Non-acute presentation 1987 788 (39.7) 812 (40.9) 387 (19.5) Acute presentation includes STEMI, NSTEMI, and unstable angina with high risk features. Non-acute presentation is limited to stable angina.