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2019 HSR&D/QUERI National Conference Abstract

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1086 — Appropriateness of Percutaneous Coronary Intervention in Patients with Stable Coronary Artery Disease: Department of Veterans Affairs, 2013-2015

Lead/Presenter: Paul Hess,  COIN - Seattle/Denver
All Authors: Hess P (Denver-Seattle COIN), Kini V (Denver-Seattle COIN), Liu W (Denver-Seattle COIN) Roldan P (Oregon Health & Sciences University) Autruong P (University of Colorado Anschutz Medical Campus) Doll JA (Denver-Seattle COIN Ho PM (Denver-Seattle COIN) Bradley SM (Allina Health)

Objectives:
Percutaneous coronary intervention (PCI) for patients with stable coronary artery disease is commonly performed in Veterans Affairs (VA) hospitals. However, the appropriateness of these procedures in contemporary practice is unknown. Using criteria issued by multiple cardiovascular professional societies in 2012, we sought to characterize rates of appropriate, uncertain, and inappropriate PCI across the VA system.

Methods:
We performed a multi-center, retrospective study of patients within the VA Clinical Assessment, Reporting, and Tracking (CART) Program with stable coronary artery disease undergoing elective PCI between November 1, 2013, and October 31, 2015. Trained personnel abstracted data on patient symptoms and stress testing results. The level of risk indicated by stress testing was adjudicated and PCI appropriateness was assessed. The extent of hospital-level variation in rates of inappropriate PCI was characterized.

Results:
Of 2622 PCIs at 66 hospitals, 800 (30.5%) were classified as appropriate, 1583 (60.4%) were classified as uncertain, and 239 (9.1%) were classified as inappropriate. Inappropriate PCIs were performed in patients with low-risk ischemia on stress testing (n = 223/382, 58.4%), with < 1 classes of antianginal medication (n = 235/1936, 12.1%), or without symptoms (n = 14/23, 60.9%). Hospital-level variation in the proportion of inappropriate PCIs was observed (median hospital rate for inappropriate PCI, 9.3%; interquartile range 6.2%-11.8%).

Implications:
In contemporary VA practice, most PCIs were classified as appropriate or uncertain. However, 9.1% were classified as inappropriate with variation across hospitals.

Impacts:
These findings will inform ongoing efforts to identify elements of hospital performance and enhance PCI-related quality of care.