Center Experiences Declining PCI Volume, Reimbursement After Implementing AUC

Implementing appropriate use criteria (AUC) for coronary revascularization led to a significant decrease both in the volume of PCI and in total reimbursement for the procedure at 1 large community hospital, according to the results of a new analysis.

In the 2 years after adopting the AUC established by multiple professional societies, the number of PCIs performed at UnityPoint Trinity Hospital (Rock Island, IL) declined by 17% in the first year and declined by another 17% in the second year. During the 2-year period after the AUC were implemented in February 2012, total hospital reimbursement for PCI decreased by 36%.

Despite the reduction in the total number of PCIs, the proportion of appropriate PCIs significantly increased in the 2 years after the criteria were put in place.

“The present study, to the best of our knowledge, is the first to consider levels of appropriate PCI use and overall declining volumes of PCI to quantify cost savings associated with AUC implementation at a single institution,” according to the researchers. Lead investigator Pranav Puri, a second-year medical student at the University of Chicago in Illinois, first presented the results at the 2015 American College of Cardiology/i2 Scientific Session in San Diego, CA. The results are now published online in the American Heart Journal.   

In investigating the economic impact of the newly implemented AUC for PCI, the researchers measured PCI volume in 12-month intervals in the 2 years before the AUC were adopted at UnityPoint Trinity Hospital. In 2010 and 2011, the hospital performed 1,414 and 1,411 PCIs, respectively. After the AUC were adopted, PCI volume declined by 17% to 1,174 cases in 2012 and by an additional 17% to 970 cases in 2013. The reduction in volume was the result of a 31% reduction in elective PCIs. The ratio of elective to acute coronary interventions decreased from 1.36 before implementing the criteria to 1.02 after adopting the AUC.

In 2011, the year before implementing the AUC, total reimbursement for PCI was $20,784,030. In 2012, there was a 26% reduction in reimbursement to UnityPoint Trinity Hospital for PCIs, with total payments down to $15,414,620. In 2013, total PCI reimbursement declined further to $13,234,680. The average reimbursement for coronary interventions declined by 11% from 2011 to 2012 but increased by 2% in 2013. 

In 2012, the first year after implementing the AUC, 76% of coronary interventions were deemed appropriate, 16% were classified as “uncertain”, 1% were inappropriate, and 7% could not be classified. In 2013, the number of appropriate procedures increased, with 84% deemed appropriate, 14% were uncertain, 1% were inappropriate, and 1% were unable to be classified.

The researchers note that effects of implementing AUC on PCI volumes and appropriateness vary between hospitals, with patient selection and assessment also varying at the hospital level. Their results—increased levels of appropriate procedures performed, lowered proportion of insufficiently assessed PCIs—also point to improvements in the patient selection process at UnityPoint Trinity after the adoption of the AUC, say the group.

The researchers say the analysis has limitations, namely that outcomes were not studied, “so we were not able to quantify costs that may have been incurred as a result of procedural complications or hospital re-admittance.” As part of the overall decline in volume, there was also a corresponding decline in the volume of “appropriate” interventions, which raises the “question of whether PCI was being underutilized following AUC implementation, and future studies should elucidate the AUC’s effects on access to care as well as quality of care,” they write.

Source: 
Puri P, Carroll J, Patterson B. Cost-savings associated with implementation of peer-review appropriate use criteria for percutaneous coronary interventions. Am J Heart. 2016;Epub ahead of print.  

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