title: Appropriateness ratings of percutaneous coronary intervention in Japan and its association with the trend of noninvasive testing.
abstract: OBJECTIVE
  The aim of this study was to evaluate the appropriateness of percutaneous coronary intervention (PCI) in Japan and clarify the association between trends of pre-procedural noninvasive testing and changes in appropriateness ratings.
  
  
  BACKGROUND
  Although PCI appropriateness criteria are widely used for quality-of-care improvement, they have not been validated internationally. Furthermore, the correlation of appropriateness ratings with implementation of newly developed noninvasive testing is unclear.
  
  
  METHODS
  We assigned an appropriateness rating to 11,258 consecutive PCIs registered in the Japanese Cardiovascular Database according to appropriateness use criteria developed in 2009 (AUC/2009) and the 2012 revised version (AUC/2012). Trends of pre-procedural noninvasive testing and appropriateness ratings were plotted; logistic regression was performed to identify inappropriate PCI predictors.
  
  
  RESULTS
  In nonacute settings, 15% of PCIs were rated inappropriate under AUC/2009, and this percent increased to 30.7% under AUC/2012 criteria. This was mostly because of the focused update of AUC, in which the patients were newly classified as inappropriate if they lacked proximal left anterior descending lesions and did not undergo pre-procedural noninvasive testing. However, these cases were simply not rated under AUC/2009. The amount of inappropriate PCIs increased over 5 years, proportional to the increase in coronary computed tomography angiography use. Use of coronary computed tomography angiography was independently associated with inappropriate PCIs (odds ratio: 1.33; p = 0.027).
  
  
  CONCLUSIONS
  In a multicenter, Japanese PCI registry, approximately one-sixth of nonacute PCIs were rated as inappropriate under AUC/2009, increasing to approximately one-third under the revised AUC/2012. This significant gap may reflect a needed shift in appropriateness recognition of methods for noninvasive pre-procedural evaluation of coronary artery disease.
authors.affiliation: Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Taku
authors.initials: T
authors.lastname: Inohara
authors.affiliation: Department of Cardiology, Keio University School of Medicine, Tokyo, Japan. Electronic address: kohsaka@cpnet.med.keio.ac.jp.
authors.forename: Shun
authors.initials: S
authors.lastname: Kohsaka
authors.affiliation: Department of Healthcare Quality Assessment, The University of Tokyo, Tokyo, Japan.
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Miyata
authors.affiliation: Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Ikuko
authors.initials: I
authors.lastname: Ueda
authors.affiliation: Department of Cardiology, Saitama City Hospital, Saitama, Japan.
authors.forename: Shiro
authors.initials: S
authors.lastname: Ishikawa
authors.affiliation: Department of Cardiology, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Japan.
authors.forename: Takahiro
authors.initials: T
authors.lastname: Ohki
authors.affiliation: Cardiovascular Center, St. Luke's International Hospital, Tokyo, Japan.
authors.forename: Yutaro
authors.initials: Y
authors.lastname: Nishi
authors.affiliation: Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Kentaro
authors.initials: K
authors.lastname: Hayashida
authors.affiliation: Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Yuichiro
authors.initials: Y
authors.lastname: Maekawa
authors.affiliation: Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Akio
authors.initials: A
authors.lastname: Kawamura
authors.affiliation: Division of Cancer Health Services Research, Center for Cancer Control and Information Services, The National Cancer Center, Tokyo, Japan.
authors.forename: Takahiro
authors.initials: T
authors.lastname: Higashi
authors.affiliation: Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Keiichi
authors.initials: K
authors.lastname: Fukuda
mesh_terms: D000368:Aged; D017023:Coronary Angiography / Q000639:trends; D003952:Diagnostic Imaging / Q000639:trends*; D005260:Female; D019983:Guideline Adherence / Q000639:trends*; D006801:Humans; D007564:Japan; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010043:Outcome and Process Assessment, Health Care / Q000639:trends*; D018579:Patient Selection; D062645:Percutaneous Coronary Intervention / Q000706:statistics & numerical data / Q000639:trends*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000639:trends*; D011237:Predictive Value of Tests; D012042:Registries; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000639:trends; D016896:Treatment Outcome; D019564:Unnecessary Procedures / Q000639:trends*
keywords: appropriateness use criteria; percutaneous coronary intervention; quality of care