Appropriateness Of Percutaneous Coronary Intervention Research Articles

OR12-3 | Appropriateness of Percutaneous Coronary Interventions in Two Academic Centers in the State of Maryland

OR12-3 | Appropriateness of Percutaneous Coronary Interventions in Two Academic Centers in the State of Maryland

E-20 | Appropriateness of Percutaneous Coronary Intervention Under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)

E-20 | Appropriateness of Percutaneous Coronary Intervention Under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)

Angina After Percutaneous Coronary Intervention: Patient and Procedural Predictors.

Twenty percent to 40% of patients are affected by angina after percutaneous coronary intervention (PCI), which is associated with anxiety, depression, impaired physical function, and reduced quality of life. Understanding patient and procedural factors associated with post-PCI angina may inform alternative approaches to treatment. Two hundred thirty patients undergoing PCI completed the Seattle Angina Questionnaire (SAQ-7) and European quality of life-5 dimension-5 level (EQ-5D-5L) questionnaires at baseline and 3 months post-PCI. Patients received blinded intracoronary physiology assessments before and after stenting. A post hoc analysis was performed to compare clinical and procedural characteristics among patients with and without post-PCI angina (defined by follow-up SAQ-angina frequency score <100). Eighty-eight of 230 patients (38.3%) reported angina 3 months post-PCI and had a higher incidence of active smoking, atrial fibrillation, and history of previous myocardial infarction or PCI. Compared with patients with no angina at follow-up, they had lower baseline SAQ summary scores (69.48±24.12 versus 50.20±22.59, P<0.001) and EQ-5D-5L health index scores (0.84±0.15 versus 0.69±0.22, P<0.001). Pre-PCI fractional flow reserve (FFR) was lower among patients who had no post-PCI angina (0.56±0.15 versus 0.62±0.13, P=0.003). Percentage change in FFR after PCI had a moderate correlation with angina frequency score at follow-up (r=0.36, P<0.0001). Patients with post-PCI angina had less improvement in FFR (43.1±33.5% versus 67.0±50.7%, P<0.001). There were no between-group differences in post-PCI FFR, coronary flow reserve, or corrected index of microcirculatory resistance. Patients with post-PCI angina had lower SAQ-summary scores (64.01±22 versus 95.16±8.72, P≤0.001) and EQ-5D-5L index scores (0.69±0.26 versus 0.91±0.17, P≤0.001) at follow-up. Larger improvements in FFR following PCI were associated with less angina and better quality of life at follow-up. In patients with stable symptoms, intracoronary physiology assessment can inform expectations of angina relief and quality of life improvement after stenting and thereby help to determine the appropriateness of PCI. URL: https://www. gov; Unique identifier: NCT03259815.

Appropriateness of Percutaneous Coronary Interventions: A Systematic Review and Meta-Analysis

Since the foundation of appropriate use criteria (AUC) for coronary revascularization, the proportion of inappropriate (later revised as "rarely inappropriate") percutaneous coronary interventions (PCIs) varied in different populations. However, the pooled inappropriate PCI rate remains unknown. We searched the PubMed, Cochrane, Embase, and Sinomed databases for studies related to AUC and PCIs. Studies that reported inappropriate/rarely appropriate PCI rates were included. A random effects model was employed in the meta-analysis because of the high statistical heterogeneity. Thirty-seven studies were included in our study, of which eight studies reported the appropriateness of acute PCIs or PCIs in acute coronary syndrome (ACS) patients, 25 studies reported the appropriateness of non-acute/elective PCIs or PCIs in non-ACS/stable ischemic heart disease (SIHD) patients, and 15 studies reported both acute and non-acute PCIs or did not distinguish the urgency of PCI. The pooled inappropriate PCI rate was 4.3% (95% CI: 2.6-6.4%) in acute scenarios, 8.9% (95% CI: 6.7-11.0%) in non-acute scenarios, and 6.1% (95% CI: 4.9-7.3%) overall. The inappropriate/rarely appropriate PCI rate was significantly higher in non-acute than acute scenarios. No difference in the inappropriate PCI rate was detected based on the study location, the country's level of development, or the presence of chronic total occlusion (CTO). The worldwide inappropriate PCI rate is generally identical but comparatively high, especially under non-acute scenarios.

Comparing the Classification of Percutaneous Coronary Interventions Using the 2012 and 2017 Appropriate Use Criteria: Insights From 245,196 Patients in the NCDR CathPCI Registry

BackgroundAppropriate use criteria (AUC) have been developed to promote the rational use of percutaneous coronary intervention (PCI) among clinicians and to provide benchmarking feedback to hospitals. The original AUC were published in 2012 and subsequently updated in 2017 to reflect emerging, contemporary evidence however the degree to which the updated guidance re-classifies PCI appropriateness is unknown. MethodsElective PCI cases from March 1, 2018 until June 30, 2021 were identified from within the NCDR CathPCI database. PCI cases were classified as ‘appropriate,’ ‘uncertain’ or ‘inappropriate’ under 2012 AUC and ‘appropriate,’ ‘may be appropriate’ or ‘rarely appropriate’ under 2017 AUC; those with missing data elements were termed ‘not mappable.’ Groups that ‘remained appropriate’ (appropriate in both 2012 and 2017), ‘became non-appropriate’ (‘appropriate’ in 2012 but became either ‘may be appropriate’ or ‘rarely appropriate in 2017) and ‘became appropriate’ (‘appropriate’ in 2017 but were ‘uncertain’ or ‘inappropriate’ in 2012) were descriptively compared. Concordance was assessed by calculation of Cohen's Kappa. ResultsA total of 245,196 patients underwent elective PCI across 1669 centers. By 2012 AUC, 44% were classified ‘appropriate,’ 28% were ‘uncertain’ and 16% were ‘inappropriate’ compared with 2017 AUC which considered 34% ‘appropriate’, 56% may be ‘appropriate’ and 4% ‘rarely appropriate’. Overall fair agreement was observed with a Kappa statistic of 0.40 (95%CI 0.396-0.403). Compared with PCI that ‘remained appropriate’ under the 2017 AUC, PCI that ‘became non-appropriate’ in 2017 were more likely to be asymptomatic, less likely to be on anti-anginals and less likely to have complex lesions. Compared with PCI that ‘became non-appropriate’, PCI that ‘became appropriate’ had a higher proportion of atypical and non-anginal symptoms and were less likely to have had positive functional tests. Procedural related outcomes were similar across all groups. A total of 29 429 PCI (12.0%) were not mappable by 2012 AUC while 16 077 (6.6%) were not mappable by 2017 AUC. ConclusionsIn this contemporary analysis of patients undergoing PCI in the United States, only fair agreement between the 2012 and updated 2017 AUC was observed. While some of this reflects the intention of the updated guidance, the large proportion that were considered ‘maybe appropriate’ or who ‘became non-appropriate’ reflect the difficulties of documenting and implementing contemporary AUC guidance.

Appropriateness of Percutaneous Coronary Intervention Performed by Japanese Expert Operators in Patients With Chronic Total Occlusion.

The appropriateness of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions has rarely been investigated.Methods and Results: The Japanese CTO-PCI Expert Registry enrolled consecutive patients undergoing CTO-PCI carried out by highly experienced Japanese CTO specialists who performed more than 50 CTO-PCIs per year and 300 CTO-PCIs in total. This study included patients undergoing CTO-PCI between January 2014 and December 2019. The appropriateness, trends, and differences among the procedures performed by the operators using the 2017 appropriate use criteria were analyzed. Furthermore, we performed a logistic regression analysis to assess whether the appropriateness was associated with in-hospital major adverse cardiovascular and cerebrovascular events (MACCE). Of the 5,062 patients who underwent CTO-PCI, 4,309 (85.1%) patients who did not undergo the non-invasive stress test were classified as having no myocardial ischemia. Of the total cases, 3,150 (62.2%) were rated as "may be appropriate," and 642 (12.7%) as "rarely appropriate" CTO-PCI cases. The sensitivity analyses showed that the number (%) of "may be appropriate" ranged from 4,125 (57.8%) to 4,744 (66.4%) and the number of "rarely appropriate" ranged from 843 (11.8%) to 970 (13.6%) among best and worst scenarios. In a large Japanese CTO-PCI registry, approximately 13% of CTO-PCI procedures were classified as "rarely appropriate". Substantial efforts would be required to decrease the number of "rarely appropriate" CTO-PCI procedures.

Clinical Ambiguity and Conflicts of Interest in Interventional Cardiology Decision Making

Problem definition: Among the most vexing issues in the U.S. healthcare ecosystem is inappropriate use of percutaneous coronary intervention (PCI) procedures, also known as overstenting. A key driver of overstenting is physician subjectivity in eyeballing a coronary angiogram. Advanced tests such as fractional flow reserve (FFR) provide more precise and objective measures of PCI appropriateness, yet the decision to perform these tests is endogenous and not immune to clinical ambiguity associated with eyeballing. Additionally, conflicts of interest, arising from revenue-generating incentives, play a role in overstenting. Academic/practical relevance: Conventional wisdom suggests more precise diagnostic testing will help reduce overtreatment. However, the literature rarely recognizes that the testing decision is itself endogenous. Our research highlights the role of endogeneity surrounding interventional cardiology decision making. Methodology: This study uses stochastic modeling and simulation. Results: Under a low conflict-of-interest level, the physician performs the advanced test for intermediate lesions. Under a high conflict-of-interest level, however, the physician would perform the advanced test only for high-grade lesions, because of a financial disincentive: Performing the advanced test may lower PCI revenue if the test results argue against the procedure. Surprisingly, despite this disincentive, a more revenue-driven physician can be more inclined to perform the advanced test. Managerial implications: Our model leads to implications for various efforts aimed at tackling overstenting: (1) Attention should be paid not only to the sheer quantity of FFR procedures but to which patients receive FFR procedures; (2) reducing the risk of the advanced test has a behavior-inducing effect, yet a modest risk reduction may lower patient welfare; and (3) offering a bonus to the physician for performing FFR procedures equal to a third of its reimbursement rate will cause only a 5% increase in average physician payment while inducing a 26% decline in overstenting. In addition, we show implementing a bundled payment scheme may discourage the use of FFR procedures and lead to more salient overstenting.

Abstract 6982: PCI Appropriateness of Use: Trends Over the Last Decade

Introduction: The Appropriate Use Criteria (AUC) for coronary revascularization have undergone 2 revisions, reflecting improved understanding of which situations percutaneous coronary intervention (PCI) optimizes patient care. Over this time, PCI appropriateness and volumes have changed with increased compliance. Accordingly, we analyzed these changes in detail. Methods: PubMed and Embase libraries identified 9 national studies evaluating appropriate use of PCI. Case appropriateness was classified as appropriate, inappropriate/rarely appropriate, uncertain/may be appropriate and unmappable. Temporal trends for each category were determined from linear regression. Student-t-test was used to compare groups using Graphpad Prism 8.0 software. Results: The total number of PCIs decreased 14.1% over the study period. This diminished volume was associated with reductions in both non-acute (from 22.5% to 16.3%, p &lt;0.01) and non-mappable PCIs (from 17.6% to 5.0%, p&lt;0.001), while acute PCIs increased (from 65.7% to 81.2%, p&lt;0.001, figure). In non-acute PCIs, appropriate PCIs increased (from 42.8% to 68.4%, p&lt;0.001) while both inappropriate (from 18.9% to 11.6%, p&lt;0.01) and uncertain (from 38.2% to 20.0%, p&lt;0.001) were reduced. Reclassification as defined in the 2017 Revision led to significant decrease in appropriate (56.8% to 48.0%, p&lt;0.01) and an increase in uncertain class (32.7% to 50.1%, p &lt;0.01). Acute PCIs showed no overall change in appropriateness. Conclusions: These findings demonstrate: 1) the overall volume of PCIs is decreasing, 2) revised classification led to more uncertain PCIs, and 3) the percent of appropriate non-acute PCIs is increasing with a decline in inappropriate and uncertain PCI. The AUC have successfully decreased the performance of inappropriate/rarely appropriate PCIs. These trends suggest either that more appropriate non-acute PCIs are being performed or better documentation has led to more accurate classification.

OR8. Appropriateness of percutaneous coronary intervention procedure in Indonesia

Abstract Background and Aims There is a possibility of the high variability of the appropriateness of PCI performed in Indonesia. It is assumed that appropriate PCI tends to have clinical outcomes than other categories. This study aimed to evaluate the appropriateness of the percutaneous coronary intervention (PCI) procedure in Indonesia. Method and Results We assigned appropriateness ratings to 214 acute coronary syndromes (ACS) and 191 stable ischemic heart disease (SIHD) records that underwent PCI in four hospitals from 2017 - 2018. The included hospitals consist of one public and three private hospitals, two cardiovascular centers, and two general hospitals with the most performed PCI procedures on 2016 - 2018 and accessible to the researchers. The PCI appropriateness was adjudicated using 2016/2017 ACC/AHA guidelines of the Appropriate Use of Care (AUC) for coronary revascularization in ACS and SIHD. The results were categorized into “appropriate”, “maybe appropriate”, and “rarely appropriate”.   The result from this study demonstrated that in ACS patients, 76.0% and 24.0% of PCI were appropriate” and “maybe appropriate”. While, in SHID patients, 68.7%, 28.7%, and 2.6% of PCI were “appropriate”, “maybe appropriate”, and “rarely appropriate”. In ACS patients, “appropriate” PCI is more commonly found in ST-elevation myocardial infarction (STEMI) cases (62.6%). In SIHD patients, 54.0% and 46.0% of left-main diseases patients underwent “maybe appropriate” and “rarely appropriate” PCI.  Conclusion The majority of PCI performed in ACS and SIHD patients from the studied hospitals are “appropriate”. 

Variability and Reproducibility of the SYNTAX Score for Triple-Vessel Disease

BackgroundThe SYNTAX score (SX) is an angiographic grading system to determine the burden and complexity of coronary artery disease (CAD) and to guide operators as to the appropriateness of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG). However, variability of the SX may exist since the assessment relies on individual clinicians to visually interpret lesion severity and characteristics. We therefore aimed to assess SX variability and reproducibility among interpreting physicians. MethodsFifty patient angiograms were randomly selected from a registry of patients with multi-vessel CAD (treated with PCI or CABG) completed at our institution during the years 2011–2018. Each angiogram was evaluated by 6 clinicians on 2 separate occasions (minimum 8 weeks between occasions) for a total of 600 SX. Our goal was to evaluate both inter- and intra- observer reliability of SX scores. Variation in both raw score as well as risk classification (low, intermediate or high SX) was observed. Inter- and intra-observer reliability were assessed using the intra-class correlation coefficient (ICC), Cohen's weighted Kappa, and Fleiss' Kappa. ResultsSYNTAX scores on both assessments and across all 6 cardiologists had a mean score of 25.3. On the first assessment, the ICC for the inter-observer reliability of SX scores was 0.61 (95% CI: 0.50, 0.73). Across the 6 observers, only 16% of angiograms were classified in the same risk classification by all observers. 34% of angiograms had less than a majority agreement (3 or less observers) on risk classification. The weighted Kappa for intra-observer reliability of risk classification scores ranged from 0.30 to 0.81. Across the 6 observers, the proportion of angiograms classified as the same risk classification between each observer's 1st and 2nd assessment ranged from 46% to 84%. ConclusionThis study shows a wide inter- and intra- user variability in calculating SX. Our data indicates a significant limitation in using the SX to guide revascularization strategies. Further studies are needed to determine more reliable ways to quantitate burden of CAD.

The DISCO study-Does Interventionalists' Sex impact Coronary Outcomes?

To examine the association of operator sex with appropriateness and outcomes of percutaneous coronary intervention (PCI). Recent studies suggest that physician sex may impact outcomes for specific patient cohorts. There are no data evaluating the impact of operator sex on PCI outcomes. We studied the impact of operator sex on PCI outcome and appropriateness among all patients undergoing PCI between January 2010 and December 2017 at 48 non-federal hospitals in Michigan. We used logistic regression models to adjust for baseline risk among patients treated by male versus female operators in the primary analysis. During this time, 18 female interventionalists and 385 male interventionalists had performed at least one PCI. Female interventionalists performed 6362 (2.7%) of 239,420 cases. There were no differences in the odds of mortality (1.48% vs. 1.56%, adjusted OR [aOR] 1.138, 95% CI: 0.891-1.452), acute kidney injury (3.42% vs. 3.28%, aOR 1.027, 95% CI: 0.819-1.288), transfusion (2.59% vs. 2.85%, aOR 1.168, 95% CI: 0.980-1.390) or major bleeding (0.95% vs. 1.07%, aOR 1.083, 95% CI: 0.825-1.420) between patients treated by female versus male interventionalist. While the absolute differences were small, PCIs performed by female interventional cardiologists were more frequently rated as appropriate (86.64% vs. 84.45%, p-value <0.0001). Female interventional cardiologists more frequently prescribed guideline-directed medical therapy. We found no significant differences in risk-adjusted in-hospital outcomes between PCIs performed by female versus male interventional cardiologists in Michigan. Female interventional cardiologists more frequently performed PCI rated as appropriate and had a higher likelihood of prescribing guideline-directed medical therapy.

Physiologic Assessment after Coronary Stent Implantation.

The presence of myocardial ischemia is a prerequisite for the benefit of coronary revascularization. In the cardiac catheterization laboratory, fractional flow reserve and non-hyperemic pressure ratios are used to define the ischemia-causing coronary stenosis, and several randomized studies showed the benefit of physiology-guided coronary revascularization. However, physiology-guided revascularization does not necessarily guarantee the relief of ischemia. Recent studies reported that residual ischemia might exist in up to 15-20% of cases after angiographically successful percutaneous coronary intervention (PCI). Therefore, post-PCI physiologic assessment is necessary for judging the appropriateness of PCI, detecting the lesions that may benefit from additional PCI, and risk stratification after PCI. This review will focus on the current evidence for post-PCI physiologic assessment, how to interpret these findings, and the future perspectives of physiologic assessment after PCI.

Abstract 15330: Association Between Elective Percutaneous Coronary Intervention Appropriateness and Publicly Reported Outcomes

Introduction: Public reporting of percutaneous coronary intervention (PCI) outcomes such as readmission and mortality may cause harm by adversely affecting patient selection for PCI. Little is known about the relationship between these outcomes and elective PCI appropriateness - a validated metric of PCI quality. Methods: We identified all patients in the national Veterans Administration healthcare system who underwent elective PCI for stable coronary disease between 2013 and 2015. We defined PCI appropriateness using 2012 criteria. The primary outcome was 90-day all-cause hospitalization or mortality. We used hierarchical Cox proportional hazards regression models adjusted for patient- and facility-level covariates to compare outcomes across PCI appropriateness categories, and a joint survival/logistic model to compare facility-level variation in inappropriate PCI and 90-day outcomes. Results: Among 2,561 patients (mean age 66 years, 99% men) undergoing PCI across 59 sites, 29.6% were classified as appropriate, 10.4% as inappropriate, and 60% as uncertain. The proportion of patients who were readmitted or died were 15.6%, 16.4%, and 15.3% among patients who received appropriate, inappropriate, and uncertain PCI respectively. There were no significant differences in 90-day outcomes between the groups (hazard ratio for appropriate compared to inappropriate PCI 0.82 [CI 0.57 to 1.17; p=0.28]). The site level covariance between inappropriate PCI and 90-day outcomes was -0.033 (95% CI -0.117 to 0.047), indicating no site-level correlation between appropriateness and 90-day outcomes (Figure). Conclusion: We found no association between elective PCI appropriateness and 90-day outcomes among a national cohort of Veterans. Including appropriateness in public reports may 1) characterize PCI quality more fully and 2) potentially mitigate the harms of reporting outcomes by empowering providers to perform appropriate PCI in higher-risk patients.

Clinical Ambiguity and Conflicts of Interest in Interventional Cardiology Decision-Making

Problem Definition: Among the most vexing issues in the U.S. healthcare ecosystem is inappropriate usage of percutaneous coronary intervention (PCI) procedures, also known as “overstenting.” A key driver of overstenting is physician subjectivity in “eyeballing” a coronary angiogram. Advanced tests such as fractional flow reserve (FFR) provide more precise and objective measures of PCI appropriateness, yet the decision to perform these tests is endogenous and not immune to clinical ambiguity associated with “eyeballing.” Additionally, conflicts of interest, arising from revenue-generating incentives, play a role in overstenting. Academic/Practical Relevance: Conventional wisdom suggests more-precise diagnostic testing will help reduce overtreatment. However, the literature rarely recognizes that the testing decision is itself endogenous. Our research highlights the role of endogeneity surrounding interventional cardiology decision-making. Methodology: Stochastic modeling and simulation. Results: Under a low conflict-of-interest level, the physician performs the advanced test for intermediate lesions. Under a high conflict-of-interest level, however, the physician would perform the advanced test only for high-grade lesions, because of a financial disincentive: Performing the advanced test may lower PCI revenue if the test results argue against the procedure. Surprisingly, despite this disincentive, a more revenue-driven physician can be more inclined to perform the advanced test. Managerial Implications: Our model leads to implications for various efforts aimed at tackling overstenting: (1) Attention should be paid not only to the sheer quantity of FFR procedures, but to which patients receive FFR procedures; (2) reducing the risk of the advanced test has a behavior-inducing effect, yet a modest risk reduction may lower patient welfare; and (3) offering a bonus to the physician for performing FFR procedures equal to a third of its reimbursement rate will cause only a 5% increase in average physician payment while inducing a 26% decline in overstenting. In addition, we show implementing a bundled-payment scheme may discourage the use of FFR procedures and lead to more salient overstenting.

Abstract 317: Implications of the Ischemia Trial Results on Appropriateness of Percutaneous Coronary Intervention for Stable Coronary Artery Disease: Insights From the Ncdr Cathpci Registry

Background: The recent ISCHEMIA trial found that percutaneous coronary intervention (PCI) did not reduce rates of cardiovascular events (death, myocardial infarction) in patients with stable ischemic heart disease (SIHD), regardless of ischemic burden, but improved patients’ health status, if they had angina. These findings have significant implications for appropriate use criteria (AUC) for PCI and suggest that PCI in asymptomatic patients may be classified as rarely appropriate given the lack of cardiovascular event or health status benefit. Methods: Patients with SIHD, who were enrolled in the NCDR Cath-PCI registry v5, from April 1 st , 2018 to June 30 th , 2019 were included in this study. To examine the potential implication of the ISCHEMIA trial on AUC, we modified the AUC definition to reclassify PCIs in asymptomatic patients with SIHD (without left main coronary artery involvement) as rarely appropriate. We then compared the current and modified AUCs. Results: Our final analytical cohort included 324,715 patients (mean age 67.9 years, 11.3% non-Caucasian, 30.4% females). At baseline, comorbidities were common with 42.9% having diabetes, 56.8% being current or recent smokers and 16.0% having chronic lung disease. Based on the current AUC definition, 113,110 (34.8%) PCIs were classified as appropriate, 79,859 (24.6%) as maybe appropriate, 6,660(2.1%) as rarely appropriate, and 125,086 (38.5%) could not be classified. Recategorizing the AUCs based on ISCHEMIA, 51,502 (15.9%) PCIs were classified as rarely appropriate; with 22,753 being reclassified from maybe appropriate and 22,089 asymptomatic patients being reclassified from unclassifiable to rarely appropriate (Figure). Conclusion: One in five patients with SIHD who undergo PCI are asymptomatic and might not be considered rarely appropriate under current AUC. The ISCHEMIA trial may have large implications on the number and proportion of patients with SIHD considered to receive little to no benefit from elective PCI.

Appropriateness of Percutaneous Coronary Interventions in Patients With Stable Coronary Artery Disease in US Department of Veterans Affairs Hospitals From 2013 to 2015

In hospitals outside of the US Department of Veterans Affairs (VA) system, 1 in 10 percutaneous coronary interventions (PCIs) for stable coronary artery disease is considered rarely appropriate by the appropriate use criteria, with variation across hospitals. The appropriateness of PCIs in VA hospitals has not been documented. To characterize the appropriateness of PCIs in VA hospitals. This retrospective cohort study included patients with stable coronary artery disease undergoing elective PCI from November 1, 2013, to October 31, 2015, within the VA Clinical Assessment, Reporting, and Tracking Program, an operational program that includes 59 VA hospitals. Data were analyzed from March 1, 2019, to August 8, 2019. Elective PCI at a VA hospital. Proportion of PCIs classified as appropriate, may be appropriate, or rarely appropriate; extent of hospital-level variation in rarely appropriate PCIs using criteria issued by cardiovascular professional societies in 2012. The extent of hospital-level variation in rates of rarely appropriate PCI was characterized using hospital proportions and random-effect logistic regression. Among 2611 patients undergoing elective PCI (mean [SD] age, 66.3 [7.6] years; 2577 [98.7%] men) at 59 hospitals, a total of 778 PCIs (29.8%) were classified as appropriate, 1561 PCIs (59.8%) were classified as may be appropriate, and 272 PCIs (10.4%) were classified as rarely appropriate. Rarely appropriate PCIs were more commonly performed in patients who had low-risk stress test findings (220 patients [89.1%]), who were taking no (100 patients [36.8%]) or 1 (167 patients [61.4%]) antianginal medication, or who had 1 coronary artery stenosis (185 patients [68.0%]). The unadjusted hospital-level rates of rarely appropriate PCIs ranged from 0% to 28.6%, with a median (interquartile range) of 9.7% (6.3%-13.9%). Random-effect models yielded an estimated median (interquartile range) rate of rarely appropriate PCI of 10.4% (8.7%-12.3%). These findings suggest that in VA practice, most PCIs for stable coronary artery disease were classified as appropriate or may be appropriate. However, 1 in 10 PCIs was classified as rarely appropriate, with variation across VA hospitals. Efforts to improve patient selection are needed.

Omission of Heart Transplant Recipients From the Appropriate Use Criteria for Revascularization and the Ramifications on Heart Transplant Centers

Guidelines endorse routine coronary angiography and percutaneous coronary intervention (PCI) to screen for and treat cardiac allograft vasculopathy in heart transplant recipients. However, the current Appropriate Use Criteria for Revascularization (AUC-R) do not recognize prior heart transplant as a unique PCI indication. Whether this affects rates of rarely appropriate (RA) PCIs is unknown. To assess the rate of RA PCI procedures in heart transplant recipients and how it pertains to hospital PCI appropriateness metrics and pay-for-performance scorecards. This observational study used National Cardiovascular Data Registry CathPCI Registry data on all patients undergoing elective PCIs from 96 Medicare-approved heart transplant centers from quarter 3 of 2009 to quarter 2 of 2017. The data were analyzed in July 2018. Prior heart transplant. Rates of RA elective PCIs in heart transplant recipients compared with nonrecipients and hospital rates of RA PCI before vs after exclusion of heart transplant recipients using paired t tests. In a subset of heart transplant centers participating in the Anthem Blue Cross and Blue Shield's Quality-In-Sights Hospital Incentive Program (Q-HIP), we compared the change in Q-HIP scorecards before vs after excluding heart transplant recipients. Of 168 802 participants, 123 124 (72.9%) were men, 137 457 were white, and the mean (SD) age was 66.3 (11.4) years. Of 168 802 elective PCIs performed in heart transplant centers, 1854 (1.1%) were for heart transplant recipients. Heart transplant recipients were less likely to have ischemic symptoms (14.6% vs 61.4%, P < .001), had lower rates of antecedent stress testing (15.0% vs 58.4%, P < .001), and had higher RA PCI rates (66.0% vs 16.9%, P < .001) compared with nonrecipients. In heart transplant centers, the absolute difference in RA rates (before vs after excluding transplant recipients) was directly associated with the proportion of PCIs performed in heart transplant recipients (r = 0.91; P < .001). In the subset of heart transplant centers participating in Q-HIP during the 2016 and 2017 calendar years, 8 of 20 (40%) and 8 of 16 centers (50%), respectively, could have benefited from a change in their Q-HIP scorecards if their RA PCI rates excluded transplant recipients. Two-thirds of PCIs in heart transplant recipients were deemed RA by the AUC-R. The failure of the AUC-R to consider prior heart transplant as a unique PCI indication may lead to inflated RA PCI rates with the potential for affecting quality reporting and pay-for-performance metrics in heart transplant centers.

Association between procedure appropriateness and patient-reported outcomes after percutaneous coronary intervention

ObjectiveThe Appropriate Use Criteria (AUC) has been used to identify individuals who are likely to benefit from percutaneous coronary intervention (PCI) for stable ischaemic heart disease. However, whether physicians reliably...

Validation of post-stenting fractional flow reserve with intravascular ultrasound parameters for optimal stent deployment.

We aimed to evaluate the relationship between post-stent fractional flow reserve (FFR) and intravascular ultrasound (IVUS) parameters for stent optimization. IVUS and FFR measurements were performed in 101 coronary lesions after successful percutaneous coronary intervention (PCI). Quantitative IVUS parameters for stent optimization such as minimal intra-stent cross sectional area (CSA), proximal, and distal reference lumen CSA, and plaque burden (PB) at both edges of the stent related to the post-stent FFR. Mean post-stent FFR was 0.91 ± 0.06. Post-stent FFR ≤ 0.90 was observed in 46 (45.5%) lesions. The 55 lesions with post-stent FFR > 0.9 had larger proximal CSA (9.2 ± 2.9mm2 vs. 7.4 ± 2.3mm2, p = 0.001), distal reference lumen CSA (7.4 ± 2.7mm2 vs. 6.3 ± 2.1mm2, p = 0.017), minimum intra-stent lumen CSA (7.4 ± 2.5mm2 vs. 6.1 ± 1.7mm2, p = 0.004), and lower proximal reference PB (45 ± 8.2% vs. 50 ± 11%, p = 0.017) than did those with post-stent FFR ≤ 0.90. Post-stent FFR had an inverse correlation with age, left anterior descending artery (LAD) against non-LAD, and proximal reference PB and a positive correlation with pre-stent FFR, proximal and distal reference lumen CSA, and minimum intra-stent lumen CSA. Meanwhile, no correlation was found between post-stent FFR and stent length. Pre-stent FFR (β = 0.544), proximal reference lumen CSA (β = 0.530) and age (β = - 0.251) were found to be independently associated with the post-stent FFR. Post-procedural FFR might partly reflect the appropriateness of PCI results in terms of the adequate expansion of the stent and full lesion coverage on IVUS.

Relationship between operator and hospital volumes and short-term mortality for percutaneous coronary intervention in New York

BackgroundRecent studies have reported mixed findings regarding the inverse provider volume-outcome relationship for percutaneous coronary interventions (PCIs). MethodsWe included patients who underwent PCIs in New York during December 2012–November 2015. Using risk-adjusted in-hospital/30-day mortality rate and appropriateness of PCI, we tested for a continuous relationship and a variety of annual PCI volume cut points at hospital and operator levels in investigating volume-outcome relationships. ResultsThere were 144,196 patients undergoing PCI procedures from 63 non-federal hospitals. There was a significant inverse association between risk-adjusted mortality and both annual hospital PCI volume and annual operator PCI volume. However, we did not find that there was an inverse hospital volume-outcome relationship for the 2013 ACCF/AHA/SCAI's hospital PCI volume cutoff value of 200 per year (AOR, 1.15, 95% CI, 0.88–1.51, P = 0.32) or a significant inverse operator volume-outcome relationship using the operator PCI volume cutoff value of 50 per year (AOR, 0.89, 95% CI, 0.70–1.12, P = 0.32) or for any other practical volume cutoffs. There was also no significant volume-outcome relationship for STEMI patients. Higher volume hospitals (>400) and operators (>200) tended to perform a higher percentage of inappropriate PCI procedures than their lower volume counterparts. ConclusionThere were no significant PCI volume-mortality relationships for either hospitals or operators for any practical volume cuts. Higher volume hospitals and operators were associated with higher percentages of inappropriate PCIs.