Most PCI procedures performed in heart transplant recipients may be considered rarely appropriate (RA) under appropriate use criteria for revascularization (AUC-R), according to a study recently published in JAMA Cardiology.

Joe X. Xie, MD, MSCR, et al., used data from ACC's CathPCI Registry to determine the rate of RA PCI procedures in heart transplant recipients vs. nonrecipients and assess the relationship between rate of RA PCI procedures and hospital PCI appropriateness metrics and pay-for-performance scorecards. The study's primary outcome was the quarterly rate of RA PCIs, defined based on the 2012 focused AUC-R update. The researchers evaluated hospital rates of RA PCIs before and after excluding heart transplant recipients for each quarter from July 2009 through June 2017. In addition, the researchers looked at whether hospitals participating in the Quality-In-Sights Hospital Incentive Program (Q-HIP) pay-for-performance initiative could have received a higher score if the RA PCI metric excluded procedures in heart transplant recipients.

A total of 168,802 elective PCIs were performed in 96 heart transplant centers during the study period, 1,854 (1.1%) of which were performed in heart transplant recipients. Compared with nonrecipients, heart transplant recipients were younger, more likely to be men, and more likely to have diabetes but less likely to have hypertension or high cholesterol. More than half of heart transplant recipients (54.8%) had received coronary revascularization.

The rate of elective RA PCI procedures was 66% in heart transplant recipients vs. 16.9% in nonrecipients. The median quarterly difference in the absolute rate of RA PCI procedures performed in transplant recipients vs. nonrecipients was 48.9% (interquartile range [IQR], 45% – 53%; p < 0.001). Among transplant patients, 20.6% of PCIs were defined as appropriate vs. 52.8% among nontransplant patients. In a subset of heart transplant centers participating in Q-HIP, eight of 20 sites (40%) in 2016 and eight of 16 (50%) in 2017 would have experienced an increased mean score if transplant PCI procedures were excluded from the RA metrics. Of these centers, two sites (10%) in 2016 and two sites (12.5%) in 2017 could have been reclassified to a higher incentive tier.

According to the researchers, heart transplant centers could be disproportionally penalized because the AUC-R does not recognize heart transplant recipients as a unique clinical population. This could "lead to inflated RA PCI rates with potential negative implications on quality metrics in heart transplant centers," they conclude.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Heart Transplant

Keywords: Reimbursement, Incentive, Benchmarking, Percutaneous Coronary Intervention, Registries, Heart Transplantation, Outcome Assessment, Health Care, Cardiology, National Cardiovascular Data Registries, CathPCI Registry

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