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CDP 12-257 – HSR&D Study

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CDP 12-257
Appropriateness of Percutaneous Coronary Intervention (CDA 10-199)
Steven M. Bradley MD MPH
Rocky Mountain Regional VA Medical Center, Aurora, CO
Aurora, CO
Funding Period: July 2012 - June 2017

BACKGROUND/RATIONALE:
Percutaneous coronary intervention (PCI) is an invasive procedure to reduce blockage in the coronary arteries. In the past decade, PCI use has increased by more than 60% to over 600,000 PCIs annually in the U.S. despite evidence that PCI offers little or no benefit for many patients, the invasive nature of the procedure incurs risk of serious adverse events, and PCI is expensive. The prevalence, risk, expense, and variation in use of PCI demand methods to guide sensible use of PCI targeted to patients who will benefit. Recently developed appropriate use criteria are intended to guide effective use of PCI. The VA is now uniquely situated to assess the appropriateness of PCI; determine the patient, provider, and system factors that influence PCI appropriateness; and provide real-time feedback of PCI appropriateness to patients and providers with the intent of improving the appropriateness of PCI performed in VA.

OBJECTIVE(S):
The objectives of this study are to 1) evaluate the distribution of appropriateness of PCI within the VA and private sectors; 2) identify from quantitative analyses characteristics of patients, providers, and the healthcare system that are associated with appropriateness of PCI; and 3) determine the influence of providing appropriateness ratings to patients and providers on PCI appropriateness.

METHODS:
To achieve these objectives, we are analyzing data from the Clinical Assessment Reporting and Tracking Program (CART). CART is a national clinical quality program for VA cath labs. The CART Program uses a software application embedded in the VA electronic health record (EHR) to collect key patient and procedural data on an estimated 10,000 PCI annually conducted in the 76 VA cath labs nationwide. This data is then linked to the VA EHR, allowing for linkage to longitudinal mortality, hospitalization, outpatient visit, medication, and laboratory data. However, anticipated updates in CART to capture necessary symptom data for PCI appropriateness assessment have not been completed. As a result, we successfully competed for an IIR to support chart abstraction to complete the study.

FINDINGS/RESULTS:
While awaiting necessary data updates in CART and initiation IIR supported chart abstraction to determine PCI appropriateness, we have completed analyses of PCI appropriateness in Washington State and the American College of Cardiology - National Cardiovascular Data Registry. These studies have validated the Appropriate Use Criteria, demonstrated broad variation in facility-level PCI appropriateness, established shortcomings in reporting of necessary data for ascertainment of PCI appropriateness, clarified the relationship between hospital PCI appropriateness and quality, and the relationship between patient selection for coronary angiography and inappropriate PCI. These studies have refined our ongoing approach to determining PCI appropriateness in the VA and supported our successful IIR proposal.

IMPACT:
To date, work supported by the CDA and CDP has validated the Appropriate Use Criteria, demonstrated broad variation in facility-level PCI appropriateness, established shortcomings in reporting of necessary data for ascertainment of PCI appropriateness, clarified the relationship between hospital PCI appropriateness and quality, and the relationship between patient selection for coronary angiography and inappropriate PCI. Future proposed research will determine the value-framework impact of inappropriate PCI (cost relative to outcomes) and provide a foundation to develop an intervention to influence the appropriateness of PCI-an invasive and costly procedure for a highly prevalent disease condition in Veterans-and thus have a large impact on the efficiency and quality of health care in VA.

PUBLICATIONS:
None at this time.


DRA: Aging, Older Veterans' Health and Care, Health Systems, Cardiovascular Disease
DRE: Technology Development and Assessment
Keywords: Outcomes - Patient
MeSH Terms: none

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