What Are Hospitals Doing With PCI Appropriateness Reports? Some Say, Not Much

Data released last week from the NCDR CathPCI Registry indicate that the volume of PCI procedures classified as “inappropriate” has been halved since AUC criteria were first created, but that some hospitals are doing a better job than others at being on target. An important piece of the AUC initiative has been providing hospitals with feedback on their behavior and how that stacks up against other institutions. The question is, how are hospitals using these data?

According to Nihar Desai, MD, MPH, of Yale-New Haven Hospital (New Haven, CT), lead author of last week’s study, the answer is somewhat surprising.

Writing in a research letter that followed the publication of their primary AUC analysis, Desai et al report that more than 1 in 4 hospitals say they are not doing any review whatsoever of the AUC data they receive, while roughly the same proportion said they are conducting daily to monthly reviews of these reports.

Strikingly, however, regularity of hospital AUC review was not associated with the proportion of PCIs classified as “rarely appropriate,” or with use of guideline-recommend pharmacotherapy or clinical outcomes.

Desai et al’s primary analysis, presented during the American Heart Association 2015 Scientific Sessions, considered 2.7 million PCI procedures performed between 2010 and 2014 at 766 hospitals. To look at how AUC information was being used, researchers surveyed a subset of 500 hospitals, asking about institutional AUC review practices between 2010 and 2012. Ultimately, 387 hospitals and approximately 130,000 nonacute PCI procedures were included in their calculations.

Overall, 27% of hospitals said they were doing regular (daily or monthly) reviews of the AUC data they were provided, 26% of hospitals said there were doing no review, and 12% did not report a frequency of review. Pattern of review—or the lack thereof—was not associated with PCI volumes, hospital ownership status, whether a hospital was a teaching hospital, or with the proportion of rarely appropriate PCIs.

Importantly, rates of in-hospital mortality and periprocedural bleeding were low overall and did not differ according to level of AUC review.

Commenting on the findings to TCTMD by email, Desai acknowledged he was “a bit surprised” by the fact that institutional review of PCI appropriateness was not linked to procedure appropriateness, or use of guideline recommended therapies because institutional review has “face validity—it should seemingly matter.”

That said, he continued, “it is important to remember what we’ve learned from other major quality improvement initiatives—the presence of review is necessary but not sufficient, as it must be coupled with other enabling structures and processes in hospitals to meaningfully impact PCI appropriateness.”

Desai also stressed that, in his view, procedural appropriateness and clinical outcomes represent “important but different dimensions of quality. Given that most inappropriate PCIs are among low-risk, non-acute PCIs it is not surprising that there isn't a direct relationship between these two.”

He gave the example of a hospital that performs nonacute PCI on low-risk patients with mild ischemia on stress test, minimal angina, and using minimal antianginal medications. This hospital “would have a very low rate of in-hospital mortality and bleeding but a high rate of inappropriate PCI,” Desai explained. “It doesn't diminish the importance of appropriateness, which aims to improve patient selection and address concerns about procedural overuse. In fact, this highlights the need to measure and report both metrics.”

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Source: 
Desai NR, Parzynski CS, Krumholz HM, et al. Patterns of institutional review of percutaneous coronary intervention appropriateness and the effect on quality of care and clinical outcomes. JAMA Int Med.2015;Epub ahead of print.

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