The use of percutaneous coronary intervention (PCI) has increased dramatically in the past decade despite evidence suggesting many patients do not benefit from the procedure. Many PCIs are performed without necessary pre-procedural diagnostic tests to target the procedure to patients likely to benefit. Furthermore, widespread variation exists in the use of PCI by geographic location, hospital, and provider factors. The rapid rise in PCI coupled with evidence of wide variation in use and failure to follow practice guidelines raise concern about the appropriateness of a large proportion of PCIs.
The objective of this study is to identify the methods needed to classify the appropriateness of PCI performed nationwide in the VA through the Cardiac Assessment Reporting and Tracking System - Cath Lab (CART-CL). Completion of the proposed project will allow an estimate of the appropriateness of PCI within the VA and identify the methods required to classify the appropriateness of all PCI within the VA automatically, using CART-CL.
We piloted our methods in the Clinical Outcomes Assessment Program (COAP), a regional quality-improvement program that captures data on all coronary revascularization procedures performed in Washington State. Beginning in June of 2009, COAP began collecting data for PCI in accordance with the ACC-NCDR CathPCI version 4.3, which includes data elements necessary for determination of appropriateness. In our analysis, we included all patients who underwent PCI in the state of Washington between January 1, 2010, and December 31, 2010. We chose our start date 6 months after the implementation of NCDR version 4.3 to provide an opportunity for all facilities to become compliant with this data collection tool. We developed an algorithm to map PCIs performed in COAP to the Appropriate Use Criteria for Coronary Revascularization and assign procedural appropriateness of "appropriate", "uncertain", or "inappropriate". This process was automated using the algorithm and data elements entered at the facility. There was no secondary chart review or manual determination of PCI appropriateness.
In a complete cohort of PCI performed in Washington State, 1% of PCI for acute indications and 17% of PCI for non-acute indications were classified as inappropriate. Half of non-acute PCI could not be classified due to missing data on non-invasive stress tests. This presents a challenge in the application of the criteria for quality improvement. We have created and tested a classification algorithm that is compatible with the current NCDR data set to allow the identification of percutaneous coronary intervention (PCI) procedures that are appropriate, uncertain, or inappropriate. With the coming update to CART-CL to include current NCDR data elements, this methodologic work will serve as the foundation for assessing the appropriateness of PCI within the VA.
CART-CL is recognized by VA clinicians, Patient Care Services, and the Office of Information as a model platform for reporting on national quality improvement efforts. Identifying methods to evaluate appropriateness of PCI automatically in CART-CL will improve the quality of care for Veterans through measurement of a potential mediator in outcomes and the identification of strategies to improve the quality of care. The efficiency of care for Veterans will be improved by ensuring PCIs are targeted to appropriate patients likely to benefit. Completion of the proposed project will allow an estimate of the appropriateness of PCI within the VA and identify the methods required to classify the appropriateness of all PCI within the VA automatically using CART-CL. Understanding the appropriateness of PCI will help ensure these procedures are targeted to patients likely to benefit. Additionally, appropriateness of care is a potential mediator in patient outcomes. Measurement of PCI appropriateness may allow identification of strategies to improve the quality of care.
- Bradley SM, Maynard C, Bryson CL. Appropriateness of percutaneous coronary interventions in Washington State. Circulation. Cardiovascular quality and outcomes. 2012 Jul 1; 5(4):445-53.
- Bradley SM, Chan PS, Spertus JA, Kennedy KF, Douglas PS, Patel MR, Anderson HV, Ting HH, Rumsfeld JS, Nallamothu BK. Hospital percutaneous coronary intervention appropriateness and in-hospital procedural outcomes: insights from the NCDR. Circulation. Cardiovascular quality and outcomes. 2012 May 10; 5(3):290-7.
- Bradley SM, Bryson CL, Maynard CC, Maddox TM, Fihn SD. Influence of recent hospitalization for non-coronary events on the use of preventive medications for coronary artery disease. Presented at: American Heart Association Annual Scientific Sessions; 2010 Nov 13; Chicago, IL.