title: Percutaneous Coronary Intervention Utilization and Appropriateness across the United States.
abstract: BACKGROUND
  Substantial geographic variation exists in percutaneous coronary intervention (PCI) use across the United States. It is unclear the extent to which high PCI utilization can be explained by PCI for inappropriate indications. The objective of this study was to examine the relationship between PCI rates across regional healthcare markets utilizing hospital referral regions (HRRs) and PCI appropriateness.
  
  
  METHODS
  The number of PCI procedures in each HRR was obtained from the 2010 100% Medicare limited data set. HRRs were divided into quintiles of PCI utilization with increasing rates of utilization progressing to quintile 5. NCDR CathPCI Registry® data were used to evaluate patient characteristics, appropriate use criteria (AUC), and outcomes across the HRR quintiles defined by PCI utilization with the study population restricted to HRRs where ≥ 80% of the PCIs were performed at institutions participating in the registry. PCI appropriateness was defined using 2012 AUC by the American College of Cardiology (ACC)/American Heart Association (AHA)/The Society for Cardiovascular Angiography and Interventions (SCAI).
  
  
  RESULTS
  Our study cohort comprised of 380,981 patients treated at 178 HRRs. Mean PCI rates per 1,000 increased from 4.6 in Quintile 1 to 10.8 in Quintile 5. The proportion of non-acute PCIs was 27.7% in Quintile 1 increasing to 30.7% in Quintile 5. Significant variation (p < 0.001) existed across the quintiles in the categorization of appropriateness across HRRs of utilization with more appropriate PCI in lower utilization areas (Appropriate: Q1, 76.53%, Q2, 75.326%, Q3, 75.23%, Q4, 73.95%, Q5, 72.768%; Inappropriate: Q1 3.92%, Q2 4.23%, Q3 4.32%, Q4 4.35%, Q5 4.05%; Uncertain: Q1 8.29%, Q2 8.84%, Q3 8.08%, Q4 9.01%, Q5 8.93%; Not Mappable: Q1 11.26%, Q2 11.67%, Q3 12.37%, Q4 12.69%, Q5 14.34%). There was no difference in risk-adjusted mortality across quintiles of PCI utilization.
  
  
  CONCLUSIONS
  Geographic regions with lower PCI rates have a higher proportion of PCIs performed for appropriate indications. Areas that perform more PCIs also appear to perform more elective PCI and many could not be mapped by the AUC.
authors.affiliation: Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America; Cardiovascular Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Thomas
authors.affiliation: Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America.
authors.forename: Craig S
authors.initials: CS
authors.lastname: Parzynski
authors.affiliation: Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America.
authors.forename: Jeptha P
authors.initials: JP
authors.lastname: Curtis
authors.affiliation: Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America.
authors.forename: Milan
authors.initials: M
authors.lastname: Seth
authors.affiliation: Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America; Cardiovascular Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America.
authors.forename: Brahmajee K
authors.initials: BK
authors.lastname: Nallamothu
authors.affiliation: Saint Luke's Mid America Heart and Vascular Institute, Kansas City, Missouri, United States of America.
authors.forename: Paul S
authors.initials: PS
authors.lastname: Chan
authors.affiliation: Saint Luke's Mid America Heart and Vascular Institute, Kansas City, Missouri, United States of America.
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina, United States of America.
authors.forename: Manesh R
authors.initials: MR
authors.lastname: Patel
authors.affiliation: Cardiovascular Medicine, University of Colorado and VA Eastern Colorado Healthcare System, Denver, Colorado, United States of America.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Bradley
authors.affiliation: Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America; Cardiovascular Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America.
authors.forename: Hitinder S
authors.initials: HS
authors.lastname: Gurm
mesh_terms: D000572:American Heart Association; D015906:Angioplasty, Balloon, Coronary / Q000706:statistics & numerical data; D015331:Cohort Studies; D003695:Delivery of Health Care / Q000706:statistics & numerical data; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D018579:Patient Selection; D062645:Percutaneous Coronary Intervention / Q000706:statistics & numerical data*; D012042:Registries / Q000706:statistics & numerical data; D014481:United States