Emory University School of Medicine, Atlanta, Georgia.
Cedars-Sinai Smidt Heart Institute, Los Angeles, California.
JAMA Cardiol. 2020 Jun 1;5(6):669-676. doi: 10.1001/jamacardio.2020.0586.
Guidelines endorse routine coronary angiography and percutaneous coronary intervention (PCI) to screen for and treat cardiac allograft vasculopathy in heart transplant recipients. However, the current Appropriate Use Criteria for Revascularization (AUC-R) do not recognize prior heart transplant as a unique PCI indication. Whether this affects rates of rarely appropriate (RA) PCIs is unknown.
To assess the rate of RA PCI procedures in heart transplant recipients and how it pertains to hospital PCI appropriateness metrics and pay-for-performance scorecards.
DESIGN, SETTING, AND PARTICIPANTS: This observational study used National Cardiovascular Data Registry CathPCI Registry data on all patients undergoing elective PCIs from 96 Medicare-approved heart transplant centers from quarter 3 of 2009 to quarter 2 of 2017. The data were analyzed in July 2018.
Prior heart transplant.
Rates of RA elective PCIs in heart transplant recipients compared with nonrecipients and hospital rates of RA PCI before vs after exclusion of heart transplant recipients using paired t tests. In a subset of heart transplant centers participating in the Anthem Blue Cross and Blue Shield's Quality-In-Sights Hospital Incentive Program (Q-HIP), we compared the change in Q-HIP scorecards before vs after excluding heart transplant recipients.
Of 168 802 participants, 123 124 (72.9%) were men, 137 457 were white, and the mean (SD) age was 66.3 (11.4) years. Of 168 802 elective PCIs performed in heart transplant centers, 1854 (1.1%) were for heart transplant recipients. Heart transplant recipients were less likely to have ischemic symptoms (14.6% vs 61.4%, P < .001), had lower rates of antecedent stress testing (15.0% vs 58.4%, P < .001), and had higher RA PCI rates (66.0% vs 16.9%, P < .001) compared with nonrecipients. In heart transplant centers, the absolute difference in RA rates (before vs after excluding transplant recipients) was directly associated with the proportion of PCIs performed in heart transplant recipients (r = 0.91; P < .001). In the subset of heart transplant centers participating in Q-HIP during the 2016 and 2017 calendar years, 8 of 20 (40%) and 8 of 16 centers (50%), respectively, could have benefited from a change in their Q-HIP scorecards if their RA PCI rates excluded transplant recipients.
Two-thirds of PCIs in heart transplant recipients were deemed RA by the AUC-R. The failure of the AUC-R to consider prior heart transplant as a unique PCI indication may lead to inflated RA PCI rates with the potential for affecting quality reporting and pay-for-performance metrics in heart transplant centers.
指南支持常规冠状动脉造影和经皮冠状动脉介入治疗（PCI），以筛查和治疗心脏移植受者的心脏移植血管病。然而，目前的血管重建适当使用标准（AUC-R）并不承认先前的心脏移植是一种独特的 PCI 适应证。这是否会影响很少适当（RA）PCI 的比率尚不清楚。
评估心脏移植受者中 RA PCI 手术的比率，以及它与医院 PCI 适当性指标和按绩效付费记分卡的关系。
设计、地点和参与者：本观察性研究使用了全国心血管数据登记处 CathPCI 登记处的数据，该数据来自 2009 年第 3 季度至 2017 年第 2 季度在 96 家经医疗保险批准的心脏移植中心进行的所有择期 PCI。数据于 2018 年 7 月进行了分析。
先前的心脏移植。
与非移植受者相比，心脏移植受者中 RA 择期 PCI 的比率，并使用配对 t 检验比较在排除心脏移植受者前后医院 RA PCI 的比率。在参与 Anthem Blue Cross 和 Blue Shield 的 Quality-In-Sights Hospital Incentive Program（Q-HIP）的一部分心脏移植中心中，我们比较了在排除心脏移植受者前后 Q-HIP 记分卡的变化。
在 168802 名参与者中，123124 名（72.9%）为男性，137457 名为白人，平均（SD）年龄为 66.3（11.4）岁。在心脏移植中心进行的 168802 例择期 PCI 中，有 1854 例（1.1%）为心脏移植受者。与非移植受者相比，心脏移植受者发生缺血症状的可能性较小（14.6%比 61.4%，P<0.001），进行先前应激试验的比率较低（15.0%比 58.4%，P<0.001），且 RA PCI 发生率较高（66.0%比 16.9%，P<0.001）。在心脏移植中心，RA 发生率的绝对差异（在排除移植受者前后）与在心脏移植受者中进行的 PCI 比例直接相关（r=0.91；P<0.001）。在参与 2016 年和 2017 年日历年度 Q-HIP 的心脏移植中心亚组中，如果他们的 RA PCI 率排除了移植受者，分别有 8/20（40%）和 8/16 个中心（50%）可以从 Q-HIP 记分卡的改变中受益。
三分之二的心脏移植受者的 PCI 被 AUC-R 认为是 RA。AUC-R 未能将先前的心脏移植视为一种独特的 PCI 适应证，可能导致 RA PCI 比率膨胀，并有可能影响心脏移植中心的质量报告和按绩效付费指标。
