Trends in PCI Appropriateness | Journal Scan

Study Questions:

What are the temporal trends in the number of percutaneous coronary intervention (PCI) procedures performed and the appropriateness of PCI?

Methods:

The investigators applied Appropriate Use Criteria to determine the appropriateness of all 51,872 PCIs performed in Washington State from 2010 through 2013. They evaluated the number of PCIs performed from 2006 through 2013 to provide a comparator period that preceded statewide appropriateness assessment beginning in 2010. The authors conducted this analysis to identify hospitals with large absolute reductions in the proportion of inappropriate PCI, consistent with the implementation of patient selection processes to optimize PCI appropriateness during the period of study. These hospital-level analyses were repeated to also assess average and temporal trends in the proportion of PCIs for insufficiently assessed clinical indications.

Results:

Between 2010 and 2013, the overall number of PCIs decreased by 6.8% (13,267 PCIs in 2010 to 12,193 in 2013) with a 43% decline in the number of PCIs for elective indications (3,818 PCIs in 2010 to 2,193 in 2013). The decline in use of elective PCIs was significantly larger following the onset of statewide PCI appropriateness assessment in 2010 (p = 0.03). The proportion of elective PCIs classified as appropriate increased from 26% in 2010 to 38% in 2013, while the proportion of inappropriate PCIs decreased from 16% to 13% (p < 0.001 for trends). Significant improvements in the proportion of inappropriate PCIs were limited to the tertile of hospitals with the largest decline in PCI classified as inappropriate (25% in 2010 to 12% in 2013; p = 0.03).

Conclusions:

The authors concluded that the use of PCI for elective indications has decreased over time, with concurrent improvements in PCI appropriateness.

Perspective:

This study assessed temporal trends in the number and appropriateness of PCIs performed in Washington State and reports a nearly 45% reduction in the number of PCIs for elective indications. Concurrent to the decline in elective PCI procedures, the appropriateness of PCI for elective indications has improved. However, these improvements were not uniform across hospitals, with a small number of hospitals already having high-quality patient selection processes. There appears to be an opportunity to identify best practices in patient assessment and selection processes through targeted investigation of these high-performing hospitals, and to validate the importance of patient selection processes identified at these hospitals with improvements in PCI appropriateness.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Surgical Procedures, Elective, Hospitals, Outcome Assessment (Health Care), Patient Selection, Percutaneous Coronary Intervention


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