The American College of Cardiology (ACC) has recently developed Appropriateness Criteria (AC) for coronary revascularization to support the rational and judicious use of percutaneous coronary intervention (PCI). Because a modified Delphi approach was used, there is an absence of clinical evidence to support the appropriateness ratings for most of the AC scenarios. This proposal will test the feasibility of applying the AC in routine clinical practice, assess variations in rates of appropriate and inappropriate PCI use nationally, and examine whether the AC are associated with objective measures of patient-centered benefit.
These aims are aligned with the NIH's priorities of improving the efficiency and appropriateness of care.
Specific Aim 1 will examine the feasibility of applying the AC in clinical practice. Data templates that capture the requisite patients'clinical, medication, imaging, and angiographic data for the AC will be developed and prospectively implemented in a 4-center study. In addition, the National Cardiovascular Data Registry (NCDR) Cath/PCI data collection tool will be modified to capture the necessary AC data elements. Finally, linking algorithms to map individual PCI procedures to the AC will be developed.
Specific Aim 2 will describe the prevalence of and variations in PCI appropriateness across hospitals participating in the NCDR Cath/PCI registry. This analysis will provide national prevalence estimates of PCI procedures that are rated appropriate, inappropriate, or uncertain, per the AC;examine the variability in the proportion of appropriate and inappropriate PCIs across institutions;and determine the degree to which overuse may account for wide variations in PCI use by correlating rates of inappropriate and uncertain PCIs within Medicare Hospital Referral Regions with variability in overall PCI use from the Dartmouth Atlas.
Specific Aim 3 will validate the ratings of the AC with objective measurements of patient benefit. Through a 4-center prospective study, 6-month changes in angina symptoms and quality of life will be assessed with the Seattle Angina Questionnaire (SAQ) and the EQ-5D instruments. Measurements of change in symptom burden and quality of life will then be correlated with ratings of appropriateness to determine if the AC are associated with objective measures of clinical benefit.
Specific Aim 4 will involve derivation of a shortened SAQ to facilitate its use in routine practice. As patients'symptoms are a critical determinant of the AC ratings, and as assignment of patients'symptom status by physicians can be highly variable, direct assessment of symptoms from patients'responses to the SAQ offers the opportunity for substantially greater reliability and fidelity. However, the full SAQ is too cumbersome to routinely collect in clinical practice. Using the extensive repository of SAQ data at our institution, a parsimonious SAQ will be derived and validated to facilitate its use in routine practice. PROJECT NARRATIVE: Recently, criteria which assess whether a balloon angioplasty or heart stent procedure is appropriate for a patient have been published by cardiology professional societies. These criteria, however, are primarily based on expert opinion rather than scientific evidence. Because these appropriateness criteria may be used to influence future decisions on angioplasty and stent procedures, this research project will validate these criteria and examine whether they are feasible to implement.

Public Health Relevance

Recently, criteria which assess whether a balloon angioplasty or heart stent procedure is appropriate for a patient have been published by cardiology professional societies. These criteria, however, are primarily based on expert opinion rather than scientific evidence. Because these appropriateness criteria may be used to influence future decisions on angioplasty and stent procedures, this research project will validate these criteria and examine whether they are feasible to implement.

Agency
National Institute of Health (NIH)
Institute
National Heart, Lung, and Blood Institute (NHLBI)
Type
Mentored Patient-Oriented Research Career Development Award (K23)
Project #
5K23HL102224-05
Application #
8629624
Study Section
Special Emphasis Panel (ZHL1-CSR-R (F1))
Program Officer
Scott, Jane
Project Start
2010-06-01
Project End
2015-02-28
Budget Start
2014-03-01
Budget End
2015-02-28
Support Year
5
Fiscal Year
2014
Total Cost
$116,208
Indirect Cost
$8,608
Name
Saint Luke's Hospital
Department
Type
DUNS #
073039653
City
Kansas City
State
MO
Country
United States
Zip Code
64111
Fendler, Timothy J; Spertus, John A; Kennedy, Kevin F et al. (2017) Association between hospital rates of early Do-Not-Resuscitate orders and favorable neurological survival among survivors of inhospital cardiac arrest. Am Heart J 193:108-116
Khera, Rohan; Chan, Paul S; Donnino, Michael et al. (2016) Hospital Variation in Time to Epinephrine for Nonshockable In-Hospital Cardiac Arrest. Circulation 134:2105-2114
Chan, Paul S; Krein, Sarah L; Tang, Fengming et al. (2016) Resuscitation Practices Associated With Survival After In-Hospital Cardiac Arrest: A Nationwide Survey. JAMA Cardiol 1:189-97
Chan, Paul S; McNally, Bryan; Nallamothu, Brahmajee K et al. (2016) Long-Term Outcomes Among Elderly Survivors of Out-of-Hospital Cardiac Arrest. J Am Heart Assoc 5:e002924
Girotra, Saket; van Diepen, Sean; Nallamothu, Brahmajee K et al. (2016) Regional Variation in Out-of-Hospital Cardiac Arrest Survival in the United States. Circulation 133:2159-68
Chan, Maya L; Spertus, John A; Tang, Fengming et al. (2016) Missed opportunities in use of medical emergency teams prior to in-hospital cardiac arrest. Am Heart J 177:87-95
Ranchord, Anil M; Spertus, John A; Buchanan, Donna M et al. (2016) Initiation of ?-blocker therapy and depression after acute myocardial infarction. Am Heart J 174:37-42
Girotra, Saket; Chan, Paul S; Bradley, Steven M (2015) Post-resuscitation care following out-of-hospital and in-hospital cardiac arrest. Heart 101:1943-9
Hsu, Jonathan C; Chan, Paul S; Tang, Fengming et al. (2015) Oral Anticoagulant Prescription in Patients With Atrial Fibrillation and a Low Risk of Thromboembolism: Insights From the NCDR PINNACLE Registry. JAMA Intern Med 175:1062-5
Hsu, Jonathan C; Chan, Paul S; Tang, Fengming et al. (2015) Differences in anticoagulant therapy prescription in patients with paroxysmal versus persistent atrial fibrillation. Am J Med 128:654.e1-654.e10

Showing the most recent 10 out of 66 publications