title: Hospital percutaneous coronary intervention appropriateness and in-hospital procedural outcomes: insights from the NCDR.
abstract: BACKGROUND
  Measurement of hospital quality has traditionally focused on processes of care and postprocedure outcomes. Appropriateness measures for percutaneous coronary intervention (PCI) assess quality as it relates to patient selection and the decision to perform PCI. The association between patient selection for PCI and processes of care and postprocedural outcomes is unknown.
  
  
  RESULTS
  We included 203 531 patients undergoing nonacute (elective) PCI from 779 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry between July 2009 and April 2011. We examined the association between a hospital's proportion of nonacute PCIs categorized as inappropriate by the 2009 Appropriate Use Criteria (AUC) for Coronary Revascularization and in-hospital mortality, bleeding complications, and use of optimal guideline-directed medical therapy at discharge (ie, aspirin, thienopyridines, and statins). When categorized as hospital tertiles, the range of inappropriate PCI was 0.0% to 8.1% in the lowest tertile, 8.1% to 15.2% in the middle tertile, and 15.2% to 58.6% in the highest tertile. Compared with lowest-tertile hospitals, mortality was not significantly different at middle-tertile (adjusted odds ratio [OR], 0.93; 95% confidence interval [CI], 0.73-1.19) or highest-tertile hospitals (OR, 1.12; 95% CI, 0.88-1.43; P=0.35 for differences between tertiles). Similarly, risk-adjusted bleeding did not vary significantly (middle-tertile OR, 1.13; 95% CI, 1.02-1.16; highest-tertile OR, 1.02; 95% CI, 0.91-1.16; P=0.07 for differences between tertiles) nor did use of optimal medical therapy at discharge (85.3% versus 85.7% versus 85.2%; P=0.58).
  
  
  CONCLUSIONS
  In a national cohort of nonacute PCIs, a hospital's proportion of inappropriate PCIs was not associated with in-hospital mortality, bleeding, or medical therapy at discharge. This suggests PCI appropriateness measures aspects of hospital PCI quality that are independent of how well the procedure is performed. Therefore, PCI appropriateness and postprocedural outcomes are both important metrics to inform PCI quality.
authors.affiliation: VA Eastern Colorado Health Care System, Denver, CO 80220-3808, USA. Steven.Bradley@va.gov
authors.forename: Steven M
authors.initials: SM
authors.lastname: Bradley
authors.forename: Paul S
authors.initials: PS
authors.lastname: Chan
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
authors.forename: Kevin F
authors.initials: KF
authors.lastname: Kennedy
authors.forename: Pamela S
authors.initials: PS
authors.lastname: Douglas
authors.forename: Manesh R
authors.initials: MR
authors.lastname: Patel
authors.forename: H Vernon
authors.initials: HV
authors.lastname: Anderson
authors.forename: Henry H
authors.initials: HH
authors.lastname: Ting
authors.forename: John S
authors.initials: JS
authors.lastname: Rumsfeld
authors.forename: Brahmajee K
authors.initials: BK
authors.lastname: Nallamothu
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data*; D002317:Cardiovascular Agents / Q000627:therapeutic use; D016009:Chi-Square Distribution; D005260:Female; D006302:Health Services Research; D006470:Hemorrhage / Q000209:etiology; D017052:Hospital Mortality; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D010351:Patient Discharge / Q000706:statistics & numerical data; D018579:Patient Selection; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data*; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
chemical_list: D002317:Cardiovascular Agents