Appropriateness of Percutaneous Coronary Interventions in Washington State

1. Appropriateness of Percutaneous Coronary Interventions in Washington State Chris L. Bryson, MD, MS, COAP Medical Director Steven M. Bradley, MD; Charles Maynard, PhD VA Puget Sound Healthcare System and University of Washington

2. Quality Improvement Protection: The programs of the Foundation for Health Care Quality have been approved by the WA State Department of Health as Coordinated Quality Improvement Programs (CQIP) under: RCW 43.70.51 “A CQIP… may shareinformation and documents… with one or more other CQIPs or committees or boards… and shall not be subject to the discovery process…”

3. What Does COAP Do? Collects data on all CABG, Valve and PCI procedures Analyzes data with feedback in the form of an annual risk-adjusted dashboard Distributes quarterly and annual descriptive reports Educates data managers Performs inter-rater reliability testing & audits Develops an ongoing QI plan dealing with participation status Improves quality of care in Washington State

4. COAP is a quality improvement organization that is data driven COAP Cardiac Quality measures are the most complete (all patients), most accurate (clinical data submitted by ‘tested’ abstractors, not billing data) and most timely (available within a few months after the close of a quarter, not a year later). Outcomes are reported as a comparison with the rest of the state hospitals Outcomes are expected to be within 2 SD of the mean COAP data is reviewed as a yearly event as well trend outcomes over time Sanctions occur if these outcomes are not met COAP is responsive to regional activities - out of hospital arrest

5. We use our data to identify best practices and rely on our practitioners to implement these best practices Best Practices: Identify, document, replicate, and evaluate the implementation of best practices Help to convene physician leaders and multidisciplinary teams with the goal of engaging them to develop sound QI approaches and promote widespread adoption.

6. PCI: Appropriate Use

7. Objectives • Reasons to measure PCI appropriateness • Appropriate Use Criteria for Coronary Revascularization • Appropriateness of PCI in Washington State • Future directions

8. Background • PCI is critical tool in the management of CAD • In patients with ACS, PCI reduces mortality and recurrent MI • For stable coronary disease, PCI offers symptom relief in appropriate patients

9. Pressures to Reduce Use of PCI • More than 1.2 million PCI are performed annually in the U.S. at $26 billion in cost • Volume- and cost-control efforts by payers have been amplified • Payer mechanisms are often intrusive, fail to improve quality, or optimal patient care

10. Appropriate Use Criteria for Coronary Revascularization • Developed by the ACC in partnership with multiple professional organizations • National standard to quantify ‘appropriateness’ of PCI for clinical scenarios • Stewards of self-regulation and an opportunity to improve effective utilization Patel MR, et al. JACC. 2009;53:530-553.

11. Objectives • Reasons to measure PCI appropriateness • Appropriate Use Criteria for Coronary Revascularization • Appropriateness of PCI in Washington State • Future directions

12. Adapted from Patel MR, et al. J Am Coll Cardiol. 2005;46:1606-13. Appropriateness Method Literature review and synthesis of the evidence List of clinical scenarios Appropriateness Determination Expert panel rates the indications 1st Round – No interaction 2nd Round – Panel interaction Appropriateness Score (7-9) Appropriate (4-6) Uncertain (1-3) Inappropriate

13. Patel MR, et al. JACC. 2009;53:530-553. Elements Defining Clinical Scenarios • Clinical presentation (e.g. ACS, stable angina) • Severity of angina (CCS classification) • Extent of ischemia on noninvasive testing and other prognostic factors (e.g. low EF, DM) • Extent of anti-anginal therapy • Extent of anatomic disease

14. Patel MR, et al. JACC. 2009;53:530-553. Definition of AppropriateCoronary Revascularization • “Coronary revascularization is appropriate when the expected benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of life) exceed the expected negative consequences of the procedure.”

15. Example Ratings - ACS Patel MR, et al. JACC. 2009;53:530-553.

16. Patel MR, et al. JACC. 2009;53:530-553. Example Ratings – Non-ACS

17. PCI Appropriateness in NCDR • More than 350,000 PCI performed nationally, 85% appropriate and 4% inappropriate • Acute indications 99% appropriate • Non-acute indications 50% appropriate and 12% inappropriate • Variation in PCI appropriateness by facility • NCDR beginning to provide feedback to participating facilities on PCI appropriateness

18. Role of Appropriate Use Criteria • Appropriate use criteria may identify appropriate practice patterns and facilitate highly effective and efficient care • Similar appropriateness across practice settings is a reasonable goal; complete elimination of “inappropriate” use is not

19. Interventionalist Perception of PCI Appropriateness • Survey of 85 interventionalists • 84% agreement in the median appropriateness rating • 94% (34 of 36) for appropriate indications • 70% (7 of 10) for inappropriate indications • Non-agreement (>25% of respondents outside the median rating) common

20. Rigorous Methodology Behind the Appropriate Use Criteria • Only 50% of technical panel members perform revascularization • Balance of interventionalists and cardiac surgeons • Ensures agreement of ratings with best evidence • Emphasis on practice patterns of appropriateness

21. Objectives • Reasons to measure PCI appropriateness • Appropriate Use Criteria for Coronary Revascularization • Appropriateness of PCI in Washington State • Future directions

22. Appropriateness of PCI in Washington State • Describe the appropriateness of all PCI performed in Washington State • Explore facility level variation in PCI appropriateness

23. Patel MR, et al. JACC. 2009;53:530-553. Methods • Washington State COAP • Statewide QI program for coronary revascularization • NCDR version 4 data elements • Mapping to the Appropriate Use Criteria • Significant stenosis> 50% left main or > 70% other epicardial coronary • Maximal anti-ischemic medical therapy at least 2 classes of therapy • Mapping minimized influence of missing data

24. Analysis Appropriateness of PCI stratified by indication Acute (acute myocardial infarction or unstable angina with high-risk features) Non-acute (stable angina)

25. Results: Patient Population 13,291 PCIs Performed at 32 Sites in Washington State 3367 (25%) Not Mapped to the Appropriate Use Criteria No Appropriateness Rating in the Criteria, n=1054 (31%) UA without High-Risk Features, n=902 (86%) Other, n=152 (14%) Missing Necessary Data, n=2313 (69%) Missing non-invasive risk assessment, n=1906 (82%) Other missing data, n=407 (18%) 9,924 PCI Mapped to Appropriate Use Criteria for Coronary Revascularization

26. Results: Detailed results data embargoed; full manuscript under consideration for publication.

27. Acute Indications After Excluding UA without High-risk Features

28. Non-Acute Indications by Facility

29. Influence of Assumed Stress Test Results for Missing Data

30. Summary • Of the >9000 PCI performed in Washington State that could be mapped to the Appropriate Use Criteria for Revascularization more than 85% were appropriate • Of PCI for non-acute indications, 10% were inappropriate even after assumptions to maximize appropriateness

31. Summary • Challenges in the application of Appropriate Use Criteria for quality improvement • Missing data on non-invasive stress testing with wide variation by facility • CABG not assessed in current study

32. Objectives • Reasons to measure PCI appropriateness • Appropriate Use Criteria for Coronary Revascularization • Appropriateness of PCI in Washington State • Future directions

33. Future Directions • Incorporation of PCI appropriateness in dashboard reports • Inappropriate PCI for acute/non-acute indications • Missing necessary data for classification • Incorporation of CABG appropriateness • Strategies to reduce variation in PCI appropriateness

34. Conclusion • Application of appropriate use criteria may identify appropriate practice patterns and facilitate highly effective and efficient care • Similar appropriateness across practice settings is a reasonable goal; complete elimination of “inappropriate” use is not

35. Thank you Contact Us: Chris Bryson, MD, MS Kristin Sitcov COAP Medical Director COAP Program Director cbryson@qulalityhealth.org ksitcov@qualityhealth.org 206.819.3638 206.682.2811, ext 23