Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection, and Appropriateness of Percutaneous Coronary Intervention.
Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection, and Appropriateness of Percutaneous Coronary Intervention.
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DOI：
10.1001/jama.2015.13764
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发表时间：
2015-11-17
期刊：
影响因子：
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通讯作者：
Curtis JP
中科院分区：
文献类型：
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作者：
Desai NR;Bradley SM;Parzynski CS;Nallamothu BK;Chan PS;Spertus JA;Patel MR;Ader J;Soufer A;Krumholz HM;Curtis JP
为严格评估和改进经皮冠状动脉介入治疗(PCI)患者的选择，制定了冠状动脉血运重建的适当使用标准。尚未审查各国在介入治疗适当性方面的趋势。在引入适当的使用标准后，检查介入治疗的使用率、患者选择和程序适当性的趋势。对2009年7月1日至2014年12月31日期间在医院连续参加NCDR-CASTI登记的患者进行了多中心、纵向、横断面分析。使用2012年冠状动脉血运重建的适当使用标准在患者和医院一级被归类为不适当的非急性PCIs的比例。研究对象包括来自766家医院的270万例经皮冠状动脉介入治疗。急性适应症的年度经皮冠状动脉介入治疗量在研究期间保持一致(2010年：377,540次；2014年：374,543次)，但非急性冠状动脉介入治疗的量从2010年的89,704次下降到2014年的59,375次。在接受非急性经皮冠状动脉介入治疗的患者中，心绞痛严重程度(CCS III/IV心绞痛，2010年和2014年分别为15.8%和38.4%)、在经皮冠状动脉介入治疗前使用抗心绞痛药物(至少两种抗心绞痛药物，2010年和2014年分别为22.3%和35.1%)以及非侵入性检查的高风险发现(分别为22.2%和33.2%)显著增加(P<；0.001)，但仅有小幅增长(2010年和2014年分别为43.7%和47.5%，p<；0.001)。被归类为不适当的非急性PCIs的比例(95%CI)从26.2%(95%CI，25.8%~26.6%)下降到13.3%(95%CI，13.1%~13.6%)，不适当PCIs的绝对数量从21781例下降到7921例。在研究期间，医院一级被归类为不适当的PCIs比例的变化持续存在(2014年中位数12.6%，IQR 5.9%-22.9%)。自2009年冠状动脉血运重建的适当使用标准公布以来，非急性经皮冠状动脉介入治疗的量显著减少。被归类为不适当的非急性PCIs的比例已经下降，尽管医院水平上不适当的PCI的差异仍然存在。
Appropriate Use Criteria for coronary revascularization were developed to critically evaluate and improve patient selection for percutaneous coronary intervention (PCI). National trends in the appropriateness of PCI have not been examined. To examine trends in PCI utilization, patient selection, and procedural appropriateness following the introduction of Appropriate Use Criteria. Multi-center, longitudinal, cross-sectional analysis of patients undergoing PCI between July 1, 2009 and December 31, 2014 at hospitals continuously participating in NCDR-CathPCI Registry over the study period. Proportion of non-acute PCIs classified as inappropriate at the patient- and hospital-level using the 2012 Appropriate Use Criteria for Coronary Revascularization. A total of 2.7 million PCI procedures from 766 hospitals were included. Annual PCI volume for acute indications was consistent over the study period (2010: 377,540; 2014: 374,543), but the volume for non-acute PCIs decreased from 89,704 in 2010 to 59,375 in 2014. Among patients undergoing non-acute PCI, there were significant increases in angina severity (CCS III/IV angina, 15.8% and 38.4% in 2010 and 2014 respectively), use of anti-anginal medications prior to PCI (at least 2 anti-anginal medication, 22.3% and 35.1% in 2010 and 2014 respectively), and high-risk findings on non-invasive testing (22.2% and 33.2% in 2010 and 2014 respectively) (p<0.001 for all), but only modest increases in multivessel CAD (43.7% and 47.5% in 2010 and 2014 respectively, p<0.001). The proportion (95% CI) of non-acute PCIs classified as inappropriate decreased from 26.2% (95% CI, 25.8%–26.6%) to 13.3% (95% CI, 13.1%–13.6%) and the absolute number of inappropriate PCIs decreased from 21,781 to 7,921. Hospital-level variation in the proportion of PCIs classified as inappropriate was persistent over the study period (median 12.6%, IQR 5.9%–22.9% in 2014). Since the publication of the Appropriate Use Criteria for Coronary Revascularization in 2009, there have been significant reductions in non-acute PCI volume. The proportion of non-acute PCIs classified as inappropriate has declined though hospital-level variation in inappropriate PCI persists.