Perspective:

The following are 10 points to remember about the 2013 Performance Measures for Adults Undergoing Percutaneous Coronary Intervention (PCI):

1. This PCI performance measure (PM) set gives a detailed discussion of the scope of the problem and opportunities for improving the quality of care provided to patients undergoing PCI.

2. The target population for the measures consists of all patients undergoing PCI for coronary artery disease. That said, a large focus of the Writing Committee was on measures aimed at patients coming to the cardiac catheterization laboratory for elective procedures (i.e., those originating as an outpatient). In selected patients undergoing elective procedures (i.e., those with chronic stable angina), there is greater controversy as to the best therapy that should be used.

3. The Writing Committee considered the key initial question of whether or not performing the PCI was ‘appropriate,’ in line with a growing body of evidence in this area. Determining procedural appropriateness for PCI is complex and requires comprehensive documentation of the procedure’s priority; presence and severity of angina symptoms; use of antianginal medical therapies; and presence and severity of stenosis, documented by angiography or other metrics of lesion severity (e.g., intravascular ultrasound or fractional flow reserve). The current PCI PM set represents the first time that a specific PM has been constructed to address procedure appropriateness in the cardiology literature.

4. The ideal approach to decision making is to involve the patient to the extent he or she wishes to be involved. Performance measurement should reflect this to the extent possible. Many patients will want to be involved in these crucial decisions, and physicians’ performance with these patients ideally would be assessed in part by surveying patients about whether their input was solicited and their preferences drove or at least influenced the decision.

5. The Writing Committee included important tasks to be done by the care team prior to the procedure including: determining whether the patient can and is likely to take dual antiplatelet therapy on an ongoing basis (an important requirement if drug-eluting stents are to be used), as well as documenting the patient’s renal function (which can influence the patient’s candidacy for the procedure as well as procedural strategies, i.e., amount of iodinated contrast).

6. This measure set also considers many procedure and post-procedure related factors that may affect patient outcomes such as use of embolic protection devices, and the documentation of dosage of ionized radiation and iodinated contrast used.

7. Given the challenges in capturing the data required, the limitations of the evidence supporting a specific threshold for operator volume and the potential for unintended consequences, the Writing Committee members have designated the operator volume metric for use in internal quality improvement only, since it does not comply with all the desirable attributes for performance measures. The Writing Committee believes it is important to encourage tracking of operator volume, but it would not be appropriate to evaluate operators based on volume of procedures alone, so this measure should not be used in accountability or public reporting programs.

8. The Writing Committee also considered that procedural quality must extend beyond the laboratory and also consider the implementation of appropriate secondary prevention cardiac rehabilitation and medications to modify long-term risk.

9. The Writing Committee considered other indicators of quality related to the interventionalist and the institution. These measures include such factors as procedural volume and whether or not the institution routinely tracks and benchmarks their care relative to others in clinical registries.

10. The field of quality assessment and performance measurement in PCI is a maturing field, and many advances are still needed. However, this initial metric set provides a solid foundation for quality improvement in the field, and sets the stage for future advancement.