A new study based on NCDR CathPCI Registry data has found that a vast majority of percutaneous coronary intervention (PCI) procedures performed in acute settings are appropriate; however, in the approximately 30% of non-acute settings, there was more variability in the grading according to ACC’s Coronary Revascularization Appropriate Use Criteria (AUC).  The study, published in JAMA, examined records from 1,091 U.S. hospitals captured between July 1, 2009, and Sept. 30, 2010, and included 500,154 cases. It found that 98.6% of PCIs performed during acute episodes of care were classified as appropriate, 0.3% were considered uncertain and only 1.1% were considered inappropriate.   

In the 30% of cases performed in more elective settings, 11.6% were classified as inappropriate. There was substantial variation noted across hospitals.  The reason for the variability may relate to multiple factors, and include patient or family expectations, un-quantitated patient characteristics, or other factors such as the practice setting. 

Background
In May, the CathPCI Registry began issuing reports to participating hospitals that offered them the ability to compare their performance against peer hospitals using ACC’s Coronary Revascularization AUC. These AUC are intended to identify care and variability in procedural performance.   Criteria for PCI have been developed by a broad group of surgeons, interventional cardiologists and general cardiologists.  Three categories (appropriate, uncertain, inappropriate) were tabulated for multiple short clinical and angiographic scenarios.  PCI was categorized as appropriate or uncertain if there was some debate of its merits, or inappropriate if there was general consensus that PCI was not merited in the specific scenario.   These criteria were then applied to patients undergoing PCI entered into the NCDR CathPCI Registry. 

The ACC believes that providing facilities with their rate of appropriate use of PCI procedures will encourage assessment and evaluation of their practices.  Identifying variability in performance compared with other hospitals can be used to develop quality improvement initiatives to ensure more optimal use of PCI and reduce either potential overuse or underuse depending on the specific setting. The Chan, et al., study represents an application of the CathPCI Registry AUC reports and highlights the value that NCDR registries can play in identifying practice patterns for individual hospitals and practices, identifying variability in performance and studying the reasons for this variability. 

Caveat
The results of the study should be interpreted knowing that AUC are suggested approaches to care. The AUC criteria represent the knowledge and experience base present at the time when the criteria are written, but there may be times when what is best for the individual patient is at variance with AUC or guidance documents. It must be remembered that AUC should not take the place of detailed discussion of the risk benefit ratio of potential procedures with the patient and family in concert with the physician providing care for that specific patient.  That interaction is crucial to patient-centered team-based care. Clinical judgment and full patient understanding should always guide care. 

More Resources
For more information on the study, click here. You can also learn more about the College’s ongoing efforts related to appropriate use of PCI and other therapies and procedures in the “Appropriate Use” issue center on CardioSource. The Wall Street Journal had a fairly balanced story on the article this well as well if you want additional perspective.