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Cost Savings Associated With Implementation of Peer-Reviewed Appropriate Use Criteria for Percutaneous Coronary Interventions
Cost Savings Associated With Implementation of Peer-Reviewed Appropriate Use Criteria for Percutaneous Coronary Interventions Pranav Puria,*, Jennifer Carroll, MSN, RNb, and Bobette Patterson, RN, MHAb Appropriate use criteria (AUC) for coronary revascularization have been developed to provide a practical standard to assess the quality of patient selection for percutaneous coronary interventions (PCI). However, the economic impact of AUC implementation has yet to be quantified. A peer-reviewed AUC process was implemented at UnityPoint Trinity in February 2012. Volumes of PCI cases were measured in 12-month intervals for 2 years after AUC implementation and compared with volumes from the corresponding 12-month intervals in the 2 years preceding implementation of AUC. Hospital reimbursement was averaged based on each year’s payer mix and reimbursement contracts. In the 2 years preceding AUC implementation, PCI volumes were similar (1,414 in 2010 and 1,411 in 2011). After AUC implementation, volumes of PCI decreased by 17% in both 2012 and 2013. From 2012 to 2013, the relative ratio of elective to acute interventions decreased from 1.36 to 1.02. In the same time frame, the proportion of appropriate PCI significantly increased from 76% to 84% (p <0.001). Total hospital reimbursement for PCI decreased by 36% after AUC implementation. In conclusion, implementation of a peer-reviewed AUC process at the UnityPoint Trinity led to significant cost savings through a large decrease in volume of PCI with concurrent improvement in PCI appropriateness. Ó 2016 Elsevier Inc. All rights reserved. (Am J Cardiol 2016;117:1289e1293)
In recent years, clinicians and policymakers alike have focused their efforts toward curbing unwarranted costs to the health care system. As the third most expensive procedure for both Medicare and third-party payers, the utilization of coronary interventions has come under increasing scrutiny.1 Through the collaborative efforts of multiple cardiovascular professional societies, appropriate use criteria (AUC) for percutaneous coronary intervention (PCI) were developed as a practical standard to assess the rational use of coronary revascularization in providing higher quality and potentially more cost-effective care. Although the validity of AUC in improving quality of care for patients with stable coronary artery disease has been established, the economic impact of implementation of AUC has yet to be quantified.2 We aimed to quantify the economic impact of the AUC by leveraging reimbursement data to longitudinally study the AUC’s effects on volumes of PCI cases at a large community hospital. Methods In the AUC, interventions are classified as “appropriate” when the “expected benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of a
University of Chicago, Chicago, Illinois; and bDepartment of Cardiology, UnityPoint Trinity, Rock Island, Illinois. Manuscript received November 29, 2015; revised manuscript received and accepted January 22, 2016. See page 1292 for disclosure information. *Corresponding author: Tel: (309) 756-6616; fax: (309) 743-6709. E-mail address: [email protected] (P. Puri). 0002-9149/16/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2016.01.025
life) exceed the expected negative consequences of the procedure.” Interventions classified as “inappropriate” or “rarely appropriate” are considered unlikely to improve health outcomes and may generate unwarranted costs to the health care system. The “uncertain” indication suggests additional factors should be considered or that further research is necessary to define the benefits of treatment.3,4 AUC for coronary revascularization were implemented at the UnityPoint Trinity in February 2012. Volumes of PCI cases were measured in 12-month intervals for 2 years after the implementation of AUC and compared with volumes from the corresponding 12-month intervals in the 2 years preceding implementation of AUC. The relative ratio of acute to elective interventions was also measured. Acute interventions were classified based on 2012 AUC.4 Over this time period, the number of interventional cardiologists in the hospital did not change, and the total number of patients seen by the cardiologists, in fact, increased. The AUC process implemented at the UnityPoint Trinity begins in the outpatient clinical setting. In the clinic, physicians record the patient’s symptoms, severity of stress test, and antianginal medications on an initial AUC form. The AUC form is transferred to the cardiac catheterization laboratory. After cardiac catheterization, the cardiologist and cardiac staff determine the appropriateness of the intervention and complete the AUC form. If an intervention is performed, the physician fills out another appropriate use form summarizing the procedure. All AUC forms are reviewed monthly by the director of the cardiac catheterization laboratory quality assurance program. Quarterly, 10 cases are peer reviewed (Figure 1). www.ajconline.org
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The American Journal of Cardiology (www.ajconline.org) Table 1 Patient characteristics Variable
Figure 1. Peer-reviewed AUC procedure.
Figure 2. Trends in volume of PCI. AUC were implemented in 2012. After AUC implementation, volume of PCI decreased by 17% in both 2012 and 2013.
Hospital reimbursement was averaged based on each year’s payer mix and reimbursement contracts. Reimbursement totals were calculated by multiplying each year’s average hospital reimbursement by the number of procedures performed. Comparisons of patient characteristics were performed using t test for continuous variables and chi-square test for categorical variables. All analyses were performed using STATA, version 14.0 (StataCorp LP, College Station, Texas), and evaluated at the significance level of 0.05. Results In the 2 years preceding implementation of the AUC, the volumes of PCI were similar. After implementation of AUC, the number of PCI decreased to 1,174 (17%) in 2012 and further to 970 (17%) in 2013 (Figure 2). Little change in patient demographics and characteristics was observed from 2010 to 2013 (Table 1). The relative ratio of elective to
Men Women Age (Years) Mean SD Median Medicare Age White Black Other Non-ST-segment elevation myocardial infarction ST-segment elevation myocardial infarction Body mass index >30kg/m2 Prior myocardial infarction ( >7 days) Prior percutaneous coronary intervention Diabetes mellitus Current/recent smoker Hypertension Dyslipidemia Prior coronary bypass Peripheral arterial disease Insurance Payers Private Medicare Medicaid None
Before AUC After AUC P-value Implementation Implementation (n¼2825) (n¼2144) 57% 43%
60% 40%
0.03
65 10 66 53% 94% 5% 1% 11%
65 10 66 53% 94% 5% 1% 18%
0.999
<0.001
5%
8%
<0.001
49% 15%
50% 17%
0.481 0.060
33%
31%
0.135
31% 22% 82% 82% 9% 15%
32% 23% 83% 73% 15% 11%
0.452 0.403 0.359 <0.001 <0.001 <0.001
76% 49% 7% 2%
82% 51% 9% 5%
<0.001 0.165 0.010 <0.001
0.986 0.960
acute interventions decreased from 1.36 to 1.02 after implementation of AUC (Table 2, Figure 3). The total number of patients seen increased from 75,467 in the 2 years preceding implementation to 91,466 in the 2 years after AUC implementation. In 2012, the first year after implementation of AUC, 894 interventions (76%) were “appropriate,” 183 interventions (16%) were “uncertain,” 14 interventions (1%) were “inappropriate,” and 83 interventions (7%) were unable to be classified by AUC. In 2013, 817 interventions (84%) were “appropriate,” 140 interventions (14%) were “uncertain,” 6 interventions (1%) were “inappropriate,” and 7 interventions (1%) were unable to be classified by AUC (Table 2, Figure 4). After implementation of the AUC, total hospital reimbursement decreased for PCI cases. Total hospital reimbursement for coronary interventions decreased by 26% from 2011 to 2012 and decreased by a further 14% in 2013. Average hospital reimbursement for interventions decreased by 11% from 2011 to 2012 and slightly increased by 2% from 2012 to 2013 (Table 3, Figure 5). Discussion Implementation of a peer-reviewed AUC process at the UnityPoint Trinity led to a continuous and consistent decrease in volumes of PCI. Compared with 2010 and 2011,
Coronary Artery Disease/AUC for PCI Cost Savings Table 2 Trends in percutaneous coronary interventions appropriateness by indication
Total Acute Elective Appropriate Uncertain Inappropriate Inadequate Assessment
2012
2013
1174 445 (41%) 607 (59%) 894 (76%) 183 (16%) 14 (1%) 83 (7%)
970 406 (48%) 417 (52%) 817 (84%) 140 (14%) 6 (1%) 7 (1%)
1291
Table 3 Trends in reimbursement for percutaneous coronary interventions P-value <0.001 <0.001
Figure 3. Distribution of acute versus elective PCI. After AUC implementation, the proportion of elective PCI decreased significantly (p <0.001).
Figure 4. Distribution of PCI by appropriateness. From 2012 to 2013, the proportion of appropriate PCI increased from 76% to 84%. The volume of PCI with insufficient preprocedural assessment to be mapped to AUC significantly decreased (p <0.001).
the 2 years preceding implementation of the AUC, the volume of PCI decreased by 24% in 2012 and 2013. From 2012 to 2013, the volume of PCI decreased by 17% as a result of a 31% reduction in elective PCI. In the same time frame, the percentage of “appropriate” PCI rose from 76% to 84%. Total hospital reimbursement for PCI decreased by 36% after implementation of AUC.
Average Percutaneous Coronary Intervention Reimbursement Volume of Percutaneous Coronary Interventions Total Percutaneous Coronary Interventions Reimbursement
2011
2012
2013
$14,730
$13,130
$13,644
1,411
1,174
970
$20,784,030
$15,414,620 $13,234,680
Figure 5. Total hospital reimbursement for PCI. Total reimbursement for PCI decreased by 36% after AUC implementation.
The AUC has provided clinicians a standardized tool to assess the quality of patient selection for PCI.3,4 Large cohort studies and studies from the NCDR CathPCI registry have shown levels of appropriate PCI use to be highly variable at the hospital level.5e7 In addition, Bradley et al8 have demonstrated trends of significantly lower volumes of elective PCI after the implementation of appropriateness assessment programs. However, 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. Previous studies have shown nearly all PCI for acute indications to be appropriate.5 Some have raised concerns that providers could inflate levels of appropriateness by lowering volumes of elective PCI whereas increasing volumes of PCI for acute indications, leaving overall volumes of PCI unchanged.8,9 However, we did not observe such trends in this study. The large decrease in volume of elective PCI was, in fact, accompanied by a small decrease in volume of acute PCI. Therefore, higher levels of appropriateness were not inflated by gaming of AUC. Data mapping clinical indications to AUC were not completely collected before 2012, but after AUC implementation, levels of appropriateness closely paralleled those observed in a recent study of PCI appropriateness in the Washington state.8 The proportion of PCI without adequate
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The American Journal of Cardiology (www.ajconline.org)
preprocedural assessment to be mapped to AUC also markedly decreased from 2012 to 2013, suggesting improving quality of patient selection for PCI. Although we observed an increase in proportion of appropriate PCI from 2012 to 2013, over the same time period, the volume of appropriate PCI decreased by 9%. With inappropriate PCI comprising w1% of total PCI, the decrease in total PCI was largely driven by lower volumes of appropriate and uncertain PCI. Ko et al10 identified significantly increased adverse outcomes when appropriate coronary revascularizations were not performed. Therefore, decreasing volumes of appropriate PCI raises the question of whether AUC implementation limited access to PCI and potentially led to underutilization of PCI?11,12 Other factors may have also contributed to lower volumes of PCI and subsequent cost savings. The results of the COURAGE trial and other studies detailing the lack of evidence supporting interventional therapy in many elective PCI settings may have also contributed to lower PCI volumes.13,14 Similarly, in recent years, interventional cardiologists have come under heightened scrutiny from payers and media because of suspected cases of fraud and abuse. This may have lead to physicians adopting more cautious practice patterns.15,16 However, it remains important to study AUC as development of AUC builds a platform for providing value-based care. The cost of PCI has come under increasing scrutiny in recent years, and with reimbursement models shifting away from fee-for-service toward bundled payments and population-based management, AUC have been looked on as possible means of curbing unwarranted costs.13,17 Lower volumes of PCI after AUC implementation led to a large decrease in total hospital reimbursement. Although nationally average hospital reimbursement for PCI has been decreasing, from 2012 to 2013, we observed a 2% increase in average reimbursement.18 This is explained by changes to both the case and payer mix after AUC implementation (Tables 1 and 2). The effects of implementation of AUC on volumes of PCI and levels of appropriateness have been highly variable across hospitals. Patient assessment and selection processes for PCI also greatly vary at the hospital level. Increased levels of appropriateness, lower proportions of insufficiently assessed PCI, and the 100% physician AUC compliance rate point to improvements in the quality of patient selection processes at the UnityPoint Trinity after AUC implementation. With appropriateness assessment beginning in the outpatient clinical setting and culminating with the peerreview of each PCI, AUC were robustly integrated into physician practice patterns. The findings of this study should be considered in light of certain limitations. First, we did not study outcomes, so we were not able to quantify costs that may have been incurred as a result of procedural complications or hospital readmittance. The decrease in volume of “appropriate” interventions raised the question of whether PCI was being underused after AUC implementation, and future studies should elucidate the AUC’s effects on access to care and quality of care. Second, we did not observe gaming of AUC by matching lower use of elective PCI with higher use of PCI for acute indications, but other means of gaming
appropriateness such as upcoding certain patient symptom burdens remain issues of concern.17 Third, incomplete data mapping clinical indications to AUC in the 2 years preceding AUC implementation limited our ability to assess AUC implementations’ effects on levels of appropriateness. However, previous studies have established AUC implementation’s effects on increasing appropriateness levels for PCI.8 Finally, as a retrospective single-institution study, this study lacked the power of a large, multi-institution prospective study. However, the peer-reviewed AUC process at the UnityPoint Trinity lowered costs while raising levels of appropriateness, and study of such a process can inform strategies to optimize implementation of AUC in the future. Disclosures The authors have no conflicts of interest to disclose. 1. Weiss A. Characteristics of operating room procedures in U.S. hospitals, 2011. Intern Med News 2008;41:1. 2. Bradley SM, Chan PS, Hartigan PM, Nallamothu BK, Weintraub WS, Sedlis SP, Dada M, Maron DJ, Kostuk WJ, Berman DS, Teo KK, Mancini GB, Boden WE, Spertus JA. Validation of the appropriate use criteria for percutaneous coronary intervention in patients with stable coronary artery disease (from the COURAGE trial). J Am Coll Cardiol 2015;116:167e173. 3. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/ SCAI/STS/AATS/AHA/ASNC 2009 appropriateness criteria for coronary revascularization: a report by the American College of Cardiology Foundation appropriateness criteria Task Force, Society for cardiovascular angiography and interventions, Society of Thoracic Surgeons, American association for Thoracic Surgery, American Heart association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of cardiovascular Computed Tomography. Circulation 2009;119:1330e1352. 4. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/ SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use criteria Task Force, Society for cardiovascular angiography and interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2012;59:857e881. 5. Chan P, Patel M, Klein LW, Krone RJ, Dehmer GJ, Kennedy K, Nallamothu BK, Weaver WD, Masoudi F, Rumsfeld J, Spertus JA. Appropriateness of percutaneous coronary intervention in the United States: insights from the NCDRCath/PCI registry. J Am Coll Cardiol 2011;57:E1151. 6. Bradley SM, Spertus JA, Kennedy KF, Nallamothu BK, Chan PS, Patel MR, Bryson CL, Malenka DJ, Rumsfeld JS. Patient selection for diagnostic coronary angiography and hospital-level PCI appropriateness: insights from the NCDR. JAMA Intern Med 2014;174: 1630e1639. 7. Hannan EL, Cozzens K, Samadashvili Z, Walford G, Jacobs AK, Holmes DR Jr, Stamato NJ, Sharma S, Venditti FJ, Fergus I, King SB III. Appropriateness of coronary revascularization for patients without acute coronary syndromes. J Am Coll Cardiol 2012;59: 1870e1876. 8. Bradley SM, Bohn CM, Malenka DJ, Graham MM, Bryson CL, Mccabe JM, Curtis JP, Lambert-Kerzner A, Maynard C. Temporal trends in percutaneous coronary intervention appropriateness clinical PERSPECTIVE. Circulation 2015;132:20e26. 9. Bradley SM, Maynard C, Bryson CL. Appropriateness of percutaneous coronary interventions in Washington State. Circ Cardiovasc Qual Outcomes 2012;5:445e453. 10. Ko DT, Guo H, Wijeysundra HC, Natarajan MK, Nagpal AD, Feindel CM, Kingsbury K, Cohen EA, Tu JV. Assessing the association of appropriateness of coronary revascularization and clinical outcomes for
Coronary Artery Disease/AUC for PCI Cost Savings patients with stable coronary artery disease. J Am Coll Cardiol 2012;60:1876e1884. 11. Patel MR. Appropriate use criteria to reduce underuse and overuse: striking the right balance. J Am Coll Cardiol 2012;60: 1885e1887. 12. Kereiakes DJ, Stone GW. Appropriate use criteria to reduce underuse and overuse of revascularization. J Am Coll Cardiol 2013;61:2024. 13. Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356: 1503e1516.
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14. Bittner V, Bertolet M, Felix RB, Farkouh ME, Goldberg S, Ramanathan KB, Redmon JB, Sperling L, Rutter MK. Comprehensive cardiovascular risk factor control improves survival. J Am Coll Cardiol 2015;66:765e773. 15. Kern MJ. Why is my lab’s PCI volume decreasing? Cath Lab Dig 2012;20. 16. Staff Printed Report on Cardiac Stent Usage at St. Joseph Medical Center, S. Prt. Printed Report No. 111e157 (2010). 17. Marso SP, Teirstein PS, Kereiakes DJ, Moses J, Lasala J, Grantham JA. Percutaneous coronary intervention use in the United States: defining measures of appropriateness. JACC Cardiovasc Interv 2012;5: 229e235. 18. Blankenship JC, Marshall JJ. Reimbursement for coronary intervention. Catheter Cardiovasc Interv 2013;81:745e747.
In recent years, clinicians and policymakers alike have focused their efforts toward curbing unwarranted costs to the health care system. As the third most expensive procedure for both Medicare and third-party payers, the utilization of coronary interventions has come under increasing scrutiny.1 Through the collaborative efforts of multiple cardiovascular professional societies, appropriate use criteria (AUC) for percutaneous coronary intervention (PCI) were developed as a practical standard to assess the rational use of coronary revascularization in providing higher quality and potentially more cost-effective care. Although the validity of AUC in improving quality of care for patients with stable coronary artery disease has been established, the economic impact of implementation of AUC has yet to be quantified.2 We aimed to quantify the economic impact of the AUC by leveraging reimbursement data to longitudinally study the AUC’s effects on volumes of PCI cases at a large community hospital. Methods In the AUC, interventions are classified as “appropriate” when the “expected benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of a
University of Chicago, Chicago, Illinois; and bDepartment of Cardiology, UnityPoint Trinity, Rock Island, Illinois. Manuscript received November 29, 2015; revised manuscript received and accepted January 22, 2016. See page 1292 for disclosure information. *Corresponding author: Tel: (309) 756-6616; fax: (309) 743-6709. E-mail address: [email protected] (P. Puri). 0002-9149/16/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2016.01.025
life) exceed the expected negative consequences of the procedure.” Interventions classified as “inappropriate” or “rarely appropriate” are considered unlikely to improve health outcomes and may generate unwarranted costs to the health care system. The “uncertain” indication suggests additional factors should be considered or that further research is necessary to define the benefits of treatment.3,4 AUC for coronary revascularization were implemented at the UnityPoint Trinity in February 2012. Volumes of PCI cases were measured in 12-month intervals for 2 years after the implementation of AUC and compared with volumes from the corresponding 12-month intervals in the 2 years preceding implementation of AUC. The relative ratio of acute to elective interventions was also measured. Acute interventions were classified based on 2012 AUC.4 Over this time period, the number of interventional cardiologists in the hospital did not change, and the total number of patients seen by the cardiologists, in fact, increased. The AUC process implemented at the UnityPoint Trinity begins in the outpatient clinical setting. In the clinic, physicians record the patient’s symptoms, severity of stress test, and antianginal medications on an initial AUC form. The AUC form is transferred to the cardiac catheterization laboratory. After cardiac catheterization, the cardiologist and cardiac staff determine the appropriateness of the intervention and complete the AUC form. If an intervention is performed, the physician fills out another appropriate use form summarizing the procedure. All AUC forms are reviewed monthly by the director of the cardiac catheterization laboratory quality assurance program. Quarterly, 10 cases are peer reviewed (Figure 1). www.ajconline.org
1290
The American Journal of Cardiology (www.ajconline.org) Table 1 Patient characteristics Variable
Figure 1. Peer-reviewed AUC procedure.
Figure 2. Trends in volume of PCI. AUC were implemented in 2012. After AUC implementation, volume of PCI decreased by 17% in both 2012 and 2013.
Hospital reimbursement was averaged based on each year’s payer mix and reimbursement contracts. Reimbursement totals were calculated by multiplying each year’s average hospital reimbursement by the number of procedures performed. Comparisons of patient characteristics were performed using t test for continuous variables and chi-square test for categorical variables. All analyses were performed using STATA, version 14.0 (StataCorp LP, College Station, Texas), and evaluated at the significance level of 0.05. Results In the 2 years preceding implementation of the AUC, the volumes of PCI were similar. After implementation of AUC, the number of PCI decreased to 1,174 (17%) in 2012 and further to 970 (17%) in 2013 (Figure 2). Little change in patient demographics and characteristics was observed from 2010 to 2013 (Table 1). The relative ratio of elective to
Men Women Age (Years) Mean SD Median Medicare Age White Black Other Non-ST-segment elevation myocardial infarction ST-segment elevation myocardial infarction Body mass index >30kg/m2 Prior myocardial infarction ( >7 days) Prior percutaneous coronary intervention Diabetes mellitus Current/recent smoker Hypertension Dyslipidemia Prior coronary bypass Peripheral arterial disease Insurance Payers Private Medicare Medicaid None
Before AUC After AUC P-value Implementation Implementation (n¼2825) (n¼2144) 57% 43%
60% 40%
0.03
65 10 66 53% 94% 5% 1% 11%
65 10 66 53% 94% 5% 1% 18%
0.999
<0.001
5%
8%
<0.001
49% 15%
50% 17%
0.481 0.060
33%
31%
0.135
31% 22% 82% 82% 9% 15%
32% 23% 83% 73% 15% 11%
0.452 0.403 0.359 <0.001 <0.001 <0.001
76% 49% 7% 2%
82% 51% 9% 5%
<0.001 0.165 0.010 <0.001
0.986 0.960
acute interventions decreased from 1.36 to 1.02 after implementation of AUC (Table 2, Figure 3). The total number of patients seen increased from 75,467 in the 2 years preceding implementation to 91,466 in the 2 years after AUC implementation. In 2012, the first year after implementation of AUC, 894 interventions (76%) were “appropriate,” 183 interventions (16%) were “uncertain,” 14 interventions (1%) were “inappropriate,” and 83 interventions (7%) were unable to be classified by AUC. In 2013, 817 interventions (84%) were “appropriate,” 140 interventions (14%) were “uncertain,” 6 interventions (1%) were “inappropriate,” and 7 interventions (1%) were unable to be classified by AUC (Table 2, Figure 4). After implementation of the AUC, total hospital reimbursement decreased for PCI cases. Total hospital reimbursement for coronary interventions decreased by 26% from 2011 to 2012 and decreased by a further 14% in 2013. Average hospital reimbursement for interventions decreased by 11% from 2011 to 2012 and slightly increased by 2% from 2012 to 2013 (Table 3, Figure 5). Discussion Implementation of a peer-reviewed AUC process at the UnityPoint Trinity led to a continuous and consistent decrease in volumes of PCI. Compared with 2010 and 2011,
Coronary Artery Disease/AUC for PCI Cost Savings Table 2 Trends in percutaneous coronary interventions appropriateness by indication
Total Acute Elective Appropriate Uncertain Inappropriate Inadequate Assessment
2012
2013
1174 445 (41%) 607 (59%) 894 (76%) 183 (16%) 14 (1%) 83 (7%)
970 406 (48%) 417 (52%) 817 (84%) 140 (14%) 6 (1%) 7 (1%)
1291
Table 3 Trends in reimbursement for percutaneous coronary interventions P-value <0.001 <0.001
Figure 3. Distribution of acute versus elective PCI. After AUC implementation, the proportion of elective PCI decreased significantly (p <0.001).
Figure 4. Distribution of PCI by appropriateness. From 2012 to 2013, the proportion of appropriate PCI increased from 76% to 84%. The volume of PCI with insufficient preprocedural assessment to be mapped to AUC significantly decreased (p <0.001).
the 2 years preceding implementation of the AUC, the volume of PCI decreased by 24% in 2012 and 2013. From 2012 to 2013, the volume of PCI decreased by 17% as a result of a 31% reduction in elective PCI. In the same time frame, the percentage of “appropriate” PCI rose from 76% to 84%. Total hospital reimbursement for PCI decreased by 36% after implementation of AUC.
Average Percutaneous Coronary Intervention Reimbursement Volume of Percutaneous Coronary Interventions Total Percutaneous Coronary Interventions Reimbursement
2011
2012
2013
$14,730
$13,130
$13,644
1,411
1,174
970
$20,784,030
$15,414,620 $13,234,680
Figure 5. Total hospital reimbursement for PCI. Total reimbursement for PCI decreased by 36% after AUC implementation.
The AUC has provided clinicians a standardized tool to assess the quality of patient selection for PCI.3,4 Large cohort studies and studies from the NCDR CathPCI registry have shown levels of appropriate PCI use to be highly variable at the hospital level.5e7 In addition, Bradley et al8 have demonstrated trends of significantly lower volumes of elective PCI after the implementation of appropriateness assessment programs. However, 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. Previous studies have shown nearly all PCI for acute indications to be appropriate.5 Some have raised concerns that providers could inflate levels of appropriateness by lowering volumes of elective PCI whereas increasing volumes of PCI for acute indications, leaving overall volumes of PCI unchanged.8,9 However, we did not observe such trends in this study. The large decrease in volume of elective PCI was, in fact, accompanied by a small decrease in volume of acute PCI. Therefore, higher levels of appropriateness were not inflated by gaming of AUC. Data mapping clinical indications to AUC were not completely collected before 2012, but after AUC implementation, levels of appropriateness closely paralleled those observed in a recent study of PCI appropriateness in the Washington state.8 The proportion of PCI without adequate
1292
The American Journal of Cardiology (www.ajconline.org)
preprocedural assessment to be mapped to AUC also markedly decreased from 2012 to 2013, suggesting improving quality of patient selection for PCI. Although we observed an increase in proportion of appropriate PCI from 2012 to 2013, over the same time period, the volume of appropriate PCI decreased by 9%. With inappropriate PCI comprising w1% of total PCI, the decrease in total PCI was largely driven by lower volumes of appropriate and uncertain PCI. Ko et al10 identified significantly increased adverse outcomes when appropriate coronary revascularizations were not performed. Therefore, decreasing volumes of appropriate PCI raises the question of whether AUC implementation limited access to PCI and potentially led to underutilization of PCI?11,12 Other factors may have also contributed to lower volumes of PCI and subsequent cost savings. The results of the COURAGE trial and other studies detailing the lack of evidence supporting interventional therapy in many elective PCI settings may have also contributed to lower PCI volumes.13,14 Similarly, in recent years, interventional cardiologists have come under heightened scrutiny from payers and media because of suspected cases of fraud and abuse. This may have lead to physicians adopting more cautious practice patterns.15,16 However, it remains important to study AUC as development of AUC builds a platform for providing value-based care. The cost of PCI has come under increasing scrutiny in recent years, and with reimbursement models shifting away from fee-for-service toward bundled payments and population-based management, AUC have been looked on as possible means of curbing unwarranted costs.13,17 Lower volumes of PCI after AUC implementation led to a large decrease in total hospital reimbursement. Although nationally average hospital reimbursement for PCI has been decreasing, from 2012 to 2013, we observed a 2% increase in average reimbursement.18 This is explained by changes to both the case and payer mix after AUC implementation (Tables 1 and 2). The effects of implementation of AUC on volumes of PCI and levels of appropriateness have been highly variable across hospitals. Patient assessment and selection processes for PCI also greatly vary at the hospital level. Increased levels of appropriateness, lower proportions of insufficiently assessed PCI, and the 100% physician AUC compliance rate point to improvements in the quality of patient selection processes at the UnityPoint Trinity after AUC implementation. With appropriateness assessment beginning in the outpatient clinical setting and culminating with the peerreview of each PCI, AUC were robustly integrated into physician practice patterns. The findings of this study should be considered in light of certain limitations. First, we did not study outcomes, so we were not able to quantify costs that may have been incurred as a result of procedural complications or hospital readmittance. The decrease in volume of “appropriate” interventions raised the question of whether PCI was being underused after AUC implementation, and future studies should elucidate the AUC’s effects on access to care and quality of care. Second, we did not observe gaming of AUC by matching lower use of elective PCI with higher use of PCI for acute indications, but other means of gaming
appropriateness such as upcoding certain patient symptom burdens remain issues of concern.17 Third, incomplete data mapping clinical indications to AUC in the 2 years preceding AUC implementation limited our ability to assess AUC implementations’ effects on levels of appropriateness. However, previous studies have established AUC implementation’s effects on increasing appropriateness levels for PCI.8 Finally, as a retrospective single-institution study, this study lacked the power of a large, multi-institution prospective study. However, the peer-reviewed AUC process at the UnityPoint Trinity lowered costs while raising levels of appropriateness, and study of such a process can inform strategies to optimize implementation of AUC in the future. Disclosures The authors have no conflicts of interest to disclose. 1. Weiss A. Characteristics of operating room procedures in U.S. hospitals, 2011. Intern Med News 2008;41:1. 2. Bradley SM, Chan PS, Hartigan PM, Nallamothu BK, Weintraub WS, Sedlis SP, Dada M, Maron DJ, Kostuk WJ, Berman DS, Teo KK, Mancini GB, Boden WE, Spertus JA. Validation of the appropriate use criteria for percutaneous coronary intervention in patients with stable coronary artery disease (from the COURAGE trial). J Am Coll Cardiol 2015;116:167e173. 3. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/ SCAI/STS/AATS/AHA/ASNC 2009 appropriateness criteria for coronary revascularization: a report by the American College of Cardiology Foundation appropriateness criteria Task Force, Society for cardiovascular angiography and interventions, Society of Thoracic Surgeons, American association for Thoracic Surgery, American Heart association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of cardiovascular Computed Tomography. Circulation 2009;119:1330e1352. 4. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/ SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use criteria Task Force, Society for cardiovascular angiography and interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2012;59:857e881. 5. Chan P, Patel M, Klein LW, Krone RJ, Dehmer GJ, Kennedy K, Nallamothu BK, Weaver WD, Masoudi F, Rumsfeld J, Spertus JA. Appropriateness of percutaneous coronary intervention in the United States: insights from the NCDRCath/PCI registry. J Am Coll Cardiol 2011;57:E1151. 6. Bradley SM, Spertus JA, Kennedy KF, Nallamothu BK, Chan PS, Patel MR, Bryson CL, Malenka DJ, Rumsfeld JS. Patient selection for diagnostic coronary angiography and hospital-level PCI appropriateness: insights from the NCDR. JAMA Intern Med 2014;174: 1630e1639. 7. Hannan EL, Cozzens K, Samadashvili Z, Walford G, Jacobs AK, Holmes DR Jr, Stamato NJ, Sharma S, Venditti FJ, Fergus I, King SB III. Appropriateness of coronary revascularization for patients without acute coronary syndromes. J Am Coll Cardiol 2012;59: 1870e1876. 8. Bradley SM, Bohn CM, Malenka DJ, Graham MM, Bryson CL, Mccabe JM, Curtis JP, Lambert-Kerzner A, Maynard C. Temporal trends in percutaneous coronary intervention appropriateness clinical PERSPECTIVE. Circulation 2015;132:20e26. 9. Bradley SM, Maynard C, Bryson CL. Appropriateness of percutaneous coronary interventions in Washington State. Circ Cardiovasc Qual Outcomes 2012;5:445e453. 10. Ko DT, Guo H, Wijeysundra HC, Natarajan MK, Nagpal AD, Feindel CM, Kingsbury K, Cohen EA, Tu JV. Assessing the association of appropriateness of coronary revascularization and clinical outcomes for
Coronary Artery Disease/AUC for PCI Cost Savings patients with stable coronary artery disease. J Am Coll Cardiol 2012;60:1876e1884. 11. Patel MR. Appropriate use criteria to reduce underuse and overuse: striking the right balance. J Am Coll Cardiol 2012;60: 1885e1887. 12. Kereiakes DJ, Stone GW. Appropriate use criteria to reduce underuse and overuse of revascularization. J Am Coll Cardiol 2013;61:2024. 13. Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356: 1503e1516.
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14. Bittner V, Bertolet M, Felix RB, Farkouh ME, Goldberg S, Ramanathan KB, Redmon JB, Sperling L, Rutter MK. Comprehensive cardiovascular risk factor control improves survival. J Am Coll Cardiol 2015;66:765e773. 15. Kern MJ. Why is my lab’s PCI volume decreasing? Cath Lab Dig 2012;20. 16. Staff Printed Report on Cardiac Stent Usage at St. Joseph Medical Center, S. Prt. Printed Report No. 111e157 (2010). 17. Marso SP, Teirstein PS, Kereiakes DJ, Moses J, Lasala J, Grantham JA. Percutaneous coronary intervention use in the United States: defining measures of appropriateness. JACC Cardiovasc Interv 2012;5: 229e235. 18. Blankenship JC, Marshall JJ. Reimbursement for coronary intervention. Catheter Cardiovasc Interv 2013;81:745e747.