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The proportion of inappropriate percutaneous intervention (PCI) procedures has dropped nationally since the 2009 release of the Appropriate Use Criteria (AUC) for Coronary Revascularization, but some institutions remain outliers.

From 2009 to 2014, the volume of non-acute PCI dropped from 89,704 to 59,375 procedures (P<0.001), , of Yale-New Haven Hospital in Connecticut, and colleagues found.

Inappropriate non-acute PCI similarly fell from 21,781 to 7,921 incidences, corresponding with its shrinking proportion among all PCIs (26.2% in 2009 versus 13.3% in 2014, P<0.001). Over the same period, the proportion of PCIs performed for acute indications increased from 69.1% to 82.0%.

However, rates of PCIs in 2014 considered inappropriate exceeded 23% at one-quarter of institutions, the researchers found; at a few, the rate surpassed 60%.

Published in the , the results "suggest that the practice of interventional cardiology has evolved since the introduction of Appropriate Use Criteria in 2009," according to the authors. They concluded that "clinicians are doing a better job of identifying and limiting non-acute PCI procedures to those patients most likely to benefit from revascularization."

In an , , of California's Stanford University, agreed, calling the recent progress "a good start." He wrote that "the majority of practicing U.S. cardiologists typically respond to data, evidence, and guidelines in a positive manner of adoption and change," adding that "cardiovascular medicine has largely committed to using evidence to guide practice."

He also praised the cardiovascular community for embracing data "in a mostly positive way" in light of new "medication that improves patient outcomes such as statin therapy" and new technology such as coronary stenting.

Desai and colleagues collected data from almost 2.7 million procedures at 766 institutions using the National Cardiovascular Data Registry's . They presented their study, "the most comprehensive examination of PCI appropriateness to date," at the American Heart Association's Scientific Sessions meeting.

Upon hospital-level analysis, Desai's study revealed inconsistencies between PCI centers in their response to the AUC. Of the worst offenders in 2009 and 2010, 56.5% demonstrated a noticeable and steady decline in their use of inappropriate PCI over the next 4 years. An additional 26.2% saw small but steady improvements, while 7.9% made large strides in cutting down on the practice. Lastly, 9.4% of the institutions reported no change at first, only to begin decreasing the proportion of inappropriate PCI in the last 2 years.

Though institutional-level changes may be needed to support appropriate PCI, , according to a separate study by Desai and colleagues that was published in JAMA Internal Medicine.

Using survey data from the , the researchers analyzed changing institutional practices after publication of the AUC. Of the 387 hospitals evaluated, however, they found that 26.1% still did not review PCI appropriateness as of 2012, while 26.9% performed daily to monthly reviews and 35.1% only conducted quarterly checks.

Interestingly, there was no relationship between the frequency of appropriateness review and a hospital's rate of inappropriate PCI, which "may reflect the fact that the frequency of appropriateness review is a limited measure of the intensity of an institution's response to the AUC and the reality that review of AUC must be coupled with other enabling structures to be effective," the authors reasoned.

"There is a pressing need to identify effective strategies that can be used to support institutional improvement of PCI appropriateness," they concluded, as , costing the healthcare system more than $12 billion annually.

Harrington offered better data collection as a potential strategy, writing that hospitals and clinicians "should be required to contribute their data to a national registry as part of the compact for federal reimbursement."

"What is needed is a national system that allows immediate real-time decision support for clinical activities fully integrated with clinical research capabilities that use constantly accumulating data and sophisticated data analytics," Harrington continued. "Only at that point will the continuously learning health care system be a reality."

From the American Heart Association: