1. COAP IN 2011 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. COAP IN 2011 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 share information and documents… with one or more other CQIPs or committees or boards… and shall not be subject to the discovery process…” Quality Improvement Protection:

3. COAP IN 2011 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 IN 2011 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. COAP IN 2011 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. COAP IN 2011 PCI: Appropriate Use

7. COAP IN 2011 Objectives Reasons to measure PCI appropriateness Appropriate Use Criteria for Coronary Revascularization Appropriateness of PCI in Washington State Future directions

8. COAP IN 2011 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. COAP IN 2011 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. COAP IN 2011 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. COAP IN 2011 Objectives Reasons to measure PCI appropriateness Appropriate Use Criteria for Coronary Revascularization Appropriateness of PCI in Washington State Future directions

12. COAP IN 2011 Appropriateness Method Adapted from Patel MR, et al. J Am Coll Cardiol. 2005;46:1606-13. Literature review and synthesis of the evidence List of clinical scenarios Expert panel rates the indications 1 st Round – No interaction 2 nd Round – Panel interaction Appropriateness Score (7-9) Appropriate (4-6) Uncertain (1-3) Inappropriate Appropriateness Determination

13. COAP IN 2011 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 Patel MR, et al. JACC. 2009;53:530-553.

14. COAP IN 2011 Definition of Appropriate Coronary 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.” Patel MR, et al. JACC. 2009;53:530-553.

15. COAP IN 2011 Example Ratings - ACS Patel MR, et al. JACC. 2009;53:530-553.

16. COAP IN 2011 Example Ratings – Non-ACS Patel MR, et al. JACC. 2009;53:530-553.

17. COAP IN 2011 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. COAP IN 2011 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. COAP IN 2011 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. COAP IN 2011 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. COAP IN 2011 Objectives Reasons to measure PCI appropriateness Appropriate Use Criteria for Coronary Revascularization Appropriateness of PCI in Washington State Future directions

22. COAP IN 2011 Appropriateness of PCI in Washington State Describe the appropriateness of all PCI performed in Washington State Explore facility level variation in PCI appropriateness

23. COAP IN 2011 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 Methods Patel MR, et al. JACC. 2009;53:530-553.

24. COAP IN 2011 Analysis Appropriateness of PCI stratified by indication Acute (acute myocardial infarction or unstable angina with high-risk features) Non-acute (stable angina)

25. COAP IN 2011 9,924 PCI Mapped to Appropriate Use Criteria for Coronary Revascularization 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%) 13,291 PCIs Performed at 32 Sites in Washington State Results: Patient Population

26. COAP IN 2011 Detailed results data embargoed; full manuscript under consideration for publication. Results:

27. COAP IN 2011 Acute Indications After Excluding UA without High-risk Features

28. COAP IN 2011 Non-Acute Indications by Facility

29. COAP IN 2011 Influence of Assumed Stress Test Results for Missing Data

30. COAP IN 2011 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. COAP IN 2011 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. COAP IN 2011 Objectives Reasons to measure PCI appropriateness Appropriate Use Criteria for Coronary Revascularization Appropriateness of PCI in Washington State Future directions

33. COAP IN 2011 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. COAP IN 2011 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. COAP IN 2011 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