Author + information
- aDepartment of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado; Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado
- bSection of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- ↵∗Address for correspondence:
Dr. Frederick A. Masoudi, Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Campus Box B132, 12401 East 17th Avenue, Room 522, Aurora, Colorado 80045.
Cardiovascular medicine in the United States faces a paradox. On one hand, significant scientific, technological, and therapeutic advances create exciting opportunities to prolong and improve patients’ lives. On the other, well-documented gaps in the quality of care, including overuse and misuse of expensive technology, have stimulated health care policy interventions intended to enhance the value (defined herein as outcomes achieved for the cost) of cardiovascular care. These policies have included public reporting of quality data, payment for performance, and alternative payment models, such as bundled payments. Nearly a decade ago, Berwick et al. (1) challenged us to focus on the “triple aim”: improving patient experience of care, enhancing the health of populations, and reducing health care costs. With the emergence of novel payment systems, the pressures to meet the triple aim have intensified, especially for costly procedures with the potential for overuse.
Against this backdrop, in 2009, the American College of Cardiology (ACC) in partnership with other professional societies released the first appropriate use criteria (AUC) for coronary revascularization (2). The AUC synthesize clinical trial evidence, practice guidelines, and expert consensus, and are intended to improve patient selection for revascularization and provide a mechanism to focus on reducing overuse of revascularization procedures (2,3). In 2011, the National Cardiovascular Data Registry’s (NCDR) CathPCI registry began providing participating hospitals feedback about the appropriateness of their percutaneous coronary intervention (PCI) procedures. Simultaneously, national quality improvement campaigns, such as the American Board of Internal Medicine’s Choosing Wisely Initiative, identified PCI appropriateness as a key area for reducing overuse, and insurers incorporated measures of PCI appropriateness into pay-for-performance programs (4,5).
The New York experience warrants particular attention. Beyond providing hospitals with information about the appropriateness of PCI procedures, New York further proposed changes to procedural reimbursement for PCI based on appropriateness. In November 2011, the state’s Health Medicaid Redesign Team (MRT) informally issued recommendations, ultimately adopted in July 2013, wherein PCIs performed for Medicaid patients that were classified as inappropriate would no longer be reimbursed (6,7). This represented the first and, to our knowledge, only instance where payment was linked directly with procedural appropriateness. Although this policy was abandoned in April 2016 and no payment was ever denied, a systematic examination of trends in utilization and characteristics of patients undergoing PCI in New York could provide important insights into these actions’ potential impact on clinical care (7).
In this issue of the Journal, Hannan et al. (8) present a longitudinal observational analysis of PCIs performed in New York from 2010 to 2014. The study used the state’s PCI Reporting System, which contains detailed sociodemographic and clinical information (including the performance and results of noninvasive testing), angiographic findings, and in-hospital outcomes across all 58 nonfederal New York PCI hospitals. The 2012 AUC were applied to determine procedural appropriateness for patients undergoing nonacute PCI. Because the state has direct control over Medicaid expenditures and had announced a policy of nonpayment for PCIs classified as inappropriate, the results were stratified by primary payer (Medicaid vs. non-Medicaid). Among patients undergoing PCI for nonacute indications, volumes declined significantly (54% overall and 52% for Medicaid patients). The proportion of procedures for stable coronary artery disease (CAD) classified as inappropriate declined from 18.6% to 11.2% among non-Medicaid patients and 15.3% to 6.8% among Medicaid patients.
In numeric terms, inappropriate PCIs among Medicaid patients dropped from 340 in 2010 to 84 in 2014, a 75% decline. Finally, the authors report a substantial decline in hospital variation in performance of inappropriate PCI. The investigators conclude that the performance of inappropriate PCI for stable CAD decreased substantially between 2010 and 2014, and “might have been influenced in part by initiatives undertaken by the New York Department of Health.”
To fully appraise these results, it is helpful to place the New York experience within a broader national perspective. A prior national study of trends in appropriateness using the ACC NCDR CathPCI Registry found that between July 2009 and December 2014, the volume of nonacute PCIs declined by 34%, with the proportion of these cases classified as inappropriate declining by 50% (9). These data identified marked national shifts in patient selection for PCI since the AUC’s introduction. Beyond the caveat that observational studies cannot prove causation, it is unclear if the trends in appropriateness in the present study reflected a broader national trend or whether they suggested influences specific to New York.
To better understand this issue, we used national data from CathPCI to calculate the proportion of PCIs classified as inappropriate in 6-month intervals (Figure 1). To determine the potential effect of the New York MRT announcement on inappropriate PCI, we modeled monthly proportions of inappropriate PCI as an interrupted time series in which the overall trend in inappropriate PCI was deconstructed into 2 components: the pre-announcement period (July 2009 through November 2011) and the post-announcement period (December 2011 through December 2014). Over the study period, the proportion of nonacute PCIs classified as inappropriate declined for New York Medicaid patients (18.6% to 7.2%), for non-Medicaid patients (22.1% to 12.9%), and non-New York Medicaid patients (24.4% to 11.8%) (p < 0.001 for all) (Figure 1).
These findings are consistent with the data presented by Hannan et al. (8). However, we found heterogeneity in the rate and timing of these declines. Specifically, among New York Medicaid beneficiaries, reductions in inappropriate PCI principally occurred after the MRT announcement. Conversely, among New York non-Medicaid patients, declines in inappropriate PCI occurred before the MRT announcement; among non-New York Medicaid patients, declines were steady over the entire study period. Altogether, these findings suggested that the announcement linking reimbursement to procedural appropriateness for New York Medicaid might well have significantly influenced patient selection for PCI.
Whether the state results are truly distinct from the national ones, we must confront a deeper issue about what these findings mean. Fewer inappropriate PCIs nationally, and in New York specifically, might reflect better patient selection of those more likely to experience an improvement in health status with PCI, or better documentation of the data used to adjudicate procedural appropriateness. Both of these possibilities would represent salutary effects of the AUC. However, it is important to note a third possibility: that the observed improvements in PCI appropriateness result from systematic upcoding of clinical severity, in particular subjective data elements such as symptom burden. Certainly, incentives for “gaming” increase proportionally with financial disincentives for performing procedures classified as inappropriate. This highlights the importance of mechanisms to assess the accuracy of data used to classify appropriateness. The NCDR has a robust, multifaceted data quality program including audits to assess the completeness, consistency, and accuracy of data submitted to all clinical registries, with a particular focus on variables that inform AUC assessments (10).
The New York state plan to deny reimbursement for inappropriate PCI procedures might appear logical, but notably, the AUC methodology articulated by the ACC and partners expressly discourages this approach. The AUC were designed to foster improvement, stimulate redesign of care pathways, and challenge conventional paradigms of the role of PCI in managing stable CAD. Although evidence-based and supported by a rigorous methodology, the AUC have well-described limitations that render them more useful on the population level and for quality improvement rather than patient-level accountability. A specific concern about applying AUCs to deny payment for individual patients is the potential unintended consequence of limiting access for patients categorized as not appropriate who would benefit from a procedure.
Undeniably, we need to emphasize value in cardiovascular medicine, to move from a fragmented, opaque, provider-centered, volume-based delivery system to one that is coordinated, transparent, patient-centered, and focused on outcomes. Evidence generated by Hannan et al. (8) suggests that interventions using the AUC may improve the value of care by reducing potentially inappropriate procedures. We must consider other consequences that may result from evolution of payment structures. In a fee-for-service environment, the principal role of the AUC has been to identify and moderate overuse. As alternative payment models proliferate and health systems and providers bear increasing financial risk, the incentives that generated overutilization of expensive technologies will be replaced with others that could stimulate underuse.
With changes in financial incentives in payment, measures of appropriateness should be coupled with measurement of underuse. This will require clinically detailed data for populations of patients potentially eligible for a procedure, a greater challenge than assessing procedural appropriateness, which requires a denominator only of those patients undergoing the procedure. Additionally, outcome measures, particularly those for procedures like elective PCI that are intended to improve symptoms, should include patient-reported measurements, such as symptom burden and quality of life. These enhancements to measurement, in conjunction with AUC, will guide the cardiovascular community in its goals to increase the value of the care we deliver.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Dr. Curtis is supported by grant U01 HL105270-05 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute; receives funding from the Centers for Medicare & Medicaid Services (CMS); and receives salary support from the American College of Cardiology. Dr. Desai is supported by grant K12 HS023000-01 from the Agency for Healthcare Research and Quality; receives research support from Johnson & Johnson through Yale University; and receives funding from CMS. Dr. Masoudi has a contract with the American College of Cardiology for his role as chief science officer of the National Cardiovascular Data Registry.
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- ↵New York State Department of Health. Medicaid Redesign Team. Basic Benefit Review Work Group. Final Recommendations. November 1, 2011. Available at: https://www.health.ny.gov/health_care/medicaid/redesign/docs/basic_benefit_review_wrk_grp_final_rpt.pdf. Accessed December 22, 2016.
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