BACKGROUND/RATIONALE:
Proper patient selection for diagnostic and therapeutic procedures is central to providing the right care for the right patient at the right time. The importance of proper patient selection is reflected in the efforts of the Choosing Wisely campaign and Appropriate Use Criteria that seek to reduce the use of medical tests and procedures that may be inappropriate (i.e. provide no patient benefit despite procedural risk). Few contemporary data exist on whether invasive and expensive diagnostic and therapeutic procedures are used inappropriately in the VA. In the care of Veterans with CAD, more than 10,000 percutaneous coronary interventions (PCI) and 50,000 stress tests are performed annually. Use of these procedures in asymptomatic CAD patients without significant ischemic or coronary disease burden is inappropriate and results in unnecessary procedural risks. Additionally, these procedures contribute more than $200 million in healthcare expenditures annually to the VA. In pilot chart review, 1 in 10 PCI and stress tests performed in the VA for stable CAD were inappropriate, suggesting 6,000 Veterans may undergo unnecessary cardiovascular procedures at a cost of $20 million annually. The prevalence, patient risks, and expense of these procedures demand further investigation to an understanding whether they are being used for the appropriate patient populations in the VA. Furthermore, in an era where the VA is increasingly asked to do more with less, it is critical to determine if inappropriate use of these procedures is a significant contributor to unnecessary costs in low-value care.

OBJECTIVE(S):
The objectives of this study are to: 1) assess the rate of percutaneous coronary interventions(PCI) and stress tests performed in asymptomatic patients classified as inappropriate by the Appropriate Use Criteria across the VA healthcare system and identify patient, provider, and environmental factors associated with inappropriate use; 2) determine the extent of variation in healthcare value that is attributable to inappropriate use of PCI and stress tests in asymptomatic patients; and 3) identify best-practices for appropriate procedural use and high-value healthcare.

METHODS:
The study cohort includes more than 40,000 patients with stable CAD diagnosed by coronary angiography performed at one of 56 VA cardiac catheterization labs between October 2011 and September 2015. Using data from the Clinical Assessment Reporting and Tracking (CART) Program enhanced by chart review, we will determine the proportion of these PCI that were in asymptomatic patients classified as inappropriate by Appropriate Use Criteria. Among CAD patients who undergo stress tests after PCI, we will complete chart review to determine procedural appropriateness while concurrently developing methods to allow prospective appropriateness measurement. In the determination of healthcare value following the diagnosis of CAD, we will include overall costs of care and clinical outcomes of mortality and non-fatal myocardial infarction.

FINDINGS/RESULTS:
Chart abstraction and data collection are on-going, no findings to date.

IMPACT:
This study has the potential to inform approaches to reducing inappropriate and low-value care, thus improving the quality of cardiovascular care for Veterans.

Important gaps in knowledge that will be addressed include:

1) The appropriateness of PCI and stress tests performed in the VA; 2) the provider and environmental factors that are associated with inappropriate use; and 3) the degree to which inappropriate care contributes to variation in healthcare value.

---

External Links for this Project

NIH Reporter

Grant Number: I01HX001778-01A2
Link: https://reporter.nih.gov/project-details/9084134

---

PUBLICATIONS:

Journal Articles

1. Jneid H, Addison D, Bhatt DL, Fonarow GC, Gokak S, Grady KL, Green LA, Heidenreich PA, Ho PM, Jurgens CY, King ML, Kumbhani DJ, Pancholy S. 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circulation. Cardiovascular quality and outcomes. 2017 Oct 1; 10(10). [view]
2. Thomas RJ, Balady G, Banka G, Beckie TM, Chiu J, Gokak S, Ho PM, Keteyian SJ, King M, Lui K, Pack Q, Sanderson BK, Wang TY. 2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circulation. Cardiovascular quality and outcomes. 2018 Apr 1; 11(4):e000037. [view]
3. Sottile PD, Kiser TH, Burnham EL, Ho PM, Allen RR, Vandivier RW, Moss M, Colorado Pulmonary Outcomes Research Group (CPOR). An Observational Study of the Efficacy of Cisatracurium Compared with Vecuronium in Patients with or at Risk for Acute Respiratory Distress Syndrome. American journal of respiratory and critical care medicine. 2018 Apr 1; 197(7):897-904. [view]
4. Hess PL, Kini V, Liu W, Roldan P, Autruong P, Grunwald GK, O'Donnell C, Doll JA, Ho PM, Bradley SM. Appropriateness of Percutaneous Coronary Interventions in Patients With Stable Coronary Artery Disease in US Department of Veterans Affairs Hospitals From 2013 to 2015. JAMA Network Open. 2020 Apr 1; 3(4):e203144. [view]
5. Kini V, Hess PL, Liu W, Grunwald G, Ho PM, Bradley SM. Association Between Elective Percutaneous Coronary Intervention Appropriateness and Publicly Reported Outcomes. Circulation. Cardiovascular quality and outcomes. 2021 Jan 1; 14(1):e007421. [view]
6. Carey EP, Nolan C, Kerns RD, Ho PM, Frank JW. Association Between Facility-Level Utilization of Non-pharmacologic Chronic Pain Treatment and Subsequent Initiation of Long-Term Opioid Therapy. Journal of general internal medicine. 2018 May 1; 33(Suppl 1):38-45. [view]
7. Kini V, Dayoub EJ, Hess PL, Marzec LN, Masoudi FA, Ho PM, Groeneveld PW. Clinical Outcomes After Cardiac Stress Testing Among US Patients Younger Than 65 Years. Journal of the American Heart Association. 2018 Mar 10; 7(6). [view]
8. Nallamothu BK, Ho PM. Frontiers in Cardiovascular Outcomes Research. Circulation. Cardiovascular quality and outcomes. 2018 Feb 1; 11(2):e004612. [view]
9. Kelmenson DA, Held N, Allen RR, Quan D, Burnham EL, Clark BJ, Ho PM, Kiser TH, Vandivier RW, Moss M. Outcomes of ICU Patients With a Discharge Diagnosis of Critical Illness Polyneuromyopathy: A Propensity-Matched Analysis. Critical care medicine. 2017 Dec 1; 45(12):2055-2060. [view]
10. Levy AE, Huang C, Huang A, Michael Ho P. Recent Approaches to Improve Medication Adherence in Patients with Coronary Heart Disease: Progress Towards a Learning Healthcare System. Current Atherosclerosis Reports. 2018 Jan 24; 20(1):5. [view]
11. Qintar M, Towheed A, Tang F, Salisbury AC, Ho PM, Grantham JA, Spertus JA, Arnold SV. The Impact of De-escalation of Antianginal Medications on Health Status After Percutaneous Coronary Intervention. Journal of the American Heart Association. 2017 Oct 20; 6(10). [view]
12. Roldan PC, Ho GY, Ho PM. Updates to Adherence to Hypertension Medications. Current Hypertension Reports. 2018 Apr 10; 20(4):34. [view]

Journal Other

1. Levy AE, Ho PM. Nonadherence in the Learning Healthcare System: Avoiding a Mountain by Seeing the Bumps. [Editorial]. Circulation. Cardiovascular quality and outcomes. 2017 Oct 1; 10(10). [view]
2. Allen LA, Ho PM. Peer Review of a Manuscript Submission: A How-To Guide for Effective and Efficient Commentary. Circulation. Cardiovascular quality and outcomes. 2017 Dec 1; 10(12). [view]
3. Kelmenson DA, Held N, Allen RR, Quan D, Burnham EL, Clark BJ, Ho PM, Kiser TH, Vandivier RW, Moss M. The authors reply. Critical care medicine. 2018 Apr 1; 46(4):e347-e348. [view]

DRA: Aging, Older Veterans' Health and Care, Cardiovascular Disease
DRE: Treatment - Implementation, TRL - Applied/Translational, Treatment - Observational, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Best Practices
MeSH Terms: none