Effects of appropriate use criteria on percutaneous coronary intervention volume and case selection

Abstract

The Appropriate Use Criteria (AUC) have served as a foundation of quality practice for two decades. Since its introduction, the AUC has undergone two revisions. These changes reflect improved understanding of clinical situations where percutaneous coronary intervention (PCI) optimizes patient outcomes. We analyzed the impact that AUC classification and its revisions have had on clinical practice. The study follows a systematic review design. PubMed and Embase libraries were queried to identify all US studies evaluating appropriate use of PCI. Eight studies were included with data from 2009–2014. Cases were classified as appropriate, inappropriate/rarely appropriate, uncertain/may be appropriate and unmappable. Temporal trends were determined from linear regression. One-way ANOVA was used to compare groups using GraphPad Prism 8.0. The total percentage of PCIs performed drastically decreased from 2010 to 2013 by 13.5%. Non-acute PCIs were significantly reduced from 20.3% to 13.5%, and unclassifiable PCIs were similarly reduced from 15.1 to 5.7% ( p < 0.001). Conversely, acute PCIs substantially increased from 64.6 to 80.8% ( p < 0.001). During this period, the actual reported numbers of acute PCIs did not significantly change, however, the volume of both non-acute and unclassifiable PCIs were significantly reduced. In acute PCIs, there were no significant alterations in any of its AUC sub-classifications. In non-acute PCIs, appropriate PCIs increased substantially from 41.3 to 57.1% ( p < 0.001), while inappropriate, uncertain and unclassifiable PCIs were significantly decreased. Lastly, re-classification as per the 2017 revision caused significant reductions in both non-acute appropriate PCIs and inappropriate PCIs while the volume of uncertain PCIs significantly increased. The overall volume of PCIs has decreased over time, where revised classification has led to more uncertain PCIs, and the percentage of appropriate non-acute PCIs increased with a decline in both inappropriate and uncertain PCIs. These findings suggest that the revisions in the AUC guidelines have successfully decreased the performance of inappropriate/rarely appropriate PCIs, and may have likely contributed to decreased PCI in stable patients.