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. 2020 Apr 1;3(4):e203144.
doi: 10.1001/jamanetworkopen.2020.3144.

Appropriateness of Percutaneous Coronary Interventions in Patients With Stable Coronary Artery Disease in US Department of Veterans Affairs Hospitals From 2013 to 2015

Paul L Hess  1   2 , Vinay Kini  1 , Wenhui Liu  2 , Paola Roldan  3 , Patrick Autruong  1 , Gary K Grunwald  1   2 , Colin O'Donnell  1   2 , Jacob A Doll  4 , P Michael Ho  1   2 , Steven M Bradley  5
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Free PMC article

Appropriateness of Percutaneous Coronary Interventions in Patients With Stable Coronary Artery Disease in US Department of Veterans Affairs Hospitals From 2013 to 2015

Paul L Hess et al. JAMA Netw Open. .
Free PMC article

Abstract

Importance: In hospitals outside of the US Department of Veterans Affairs (VA) system, 1 in 10 percutaneous coronary interventions (PCIs) for stable coronary artery disease is considered rarely appropriate by the appropriate use criteria, with variation across hospitals. The appropriateness of PCIs in VA hospitals has not been documented.

Objective: To characterize the appropriateness of PCIs in VA hospitals.

Design, setting, and participants: This retrospective cohort study included patients with stable coronary artery disease undergoing elective PCI from November 1, 2013, to October 31, 2015, within the VA Clinical Assessment, Reporting, and Tracking Program, an operational program that includes 59 VA hospitals. Data were analyzed from March 1, 2019, to August 8, 2019.

Exposures: Elective PCI at a VA hospital.

Main outcomes and measures: Proportion of PCIs classified as appropriate, may be appropriate, or rarely appropriate; extent of hospital-level variation in rarely appropriate PCIs using criteria issued by cardiovascular professional societies in 2012. The extent of hospital-level variation in rates of rarely appropriate PCI was characterized using hospital proportions and random-effect logistic regression.

Results: Among 2611 patients undergoing elective PCI (mean [SD] age, 66.3 [7.6] years; 2577 [98.7%] men) at 59 hospitals, a total of 778 PCIs (29.8%) were classified as appropriate, 1561 PCIs (59.8%) were classified as may be appropriate, and 272 PCIs (10.4%) were classified as rarely appropriate. Rarely appropriate PCIs were more commonly performed in patients who had low-risk stress test findings (220 patients [89.1%]), who were taking no (100 patients [36.8%]) or 1 (167 patients [61.4%]) antianginal medication, or who had 1 coronary artery stenosis (185 patients [68.0%]). The unadjusted hospital-level rates of rarely appropriate PCIs ranged from 0% to 28.6%, with a median (interquartile range) of 9.7% (6.3%-13.9%). Random-effect models yielded an estimated median (interquartile range) rate of rarely appropriate PCI of 10.4% (8.7%-12.3%).

Conclusions and relevance: These findings suggest that in VA practice, most PCIs for stable coronary artery disease were classified as appropriate or may be appropriate. However, 1 in 10 PCIs was classified as rarely appropriate, with variation across VA hospitals. Efforts to improve patient selection are needed.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Hess reported receiving a grant from the US Department of Veterans Affairs (VA) Health Services Research and Development (HSRD) during the conduct of the study. Dr Kini reported receiving grants from the National Institutes of Health and National Heart, Lung, and Blood Institute (NHLBI). Dr Ho reported receiving grants from NHLBI, VA HSRD, and Bristol-Myers Squibb (through the University of Colorado School of Medicine) and serving as the deputy editor for Circulation: Cardiovascular Quality and Outcomes. Dr Bradley reported receiving grants from the VA HSRD during the conduct of the study. No other disclosures were reported.

Figures

Figure.
Figure.. Variation in the Proportion of Rarely Appropriate Percutaneous Coronary Interventions (PCIs) Across Hospitals
The unadjusted proportion of rarely appropriate PCIs ranged from 0% to 28.6% with a median (interquartile range) of 9.7% (6.3%-13.9%).
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