Just How Much PCI Has Shifted to Outpatient Settings?

Percutaneous coronary intervention (PCI) rates held steady after a COURAGE trial-related dip but have increasingly moved to the outpatient setting, population-based data from several states showed.

Rates of PCI declined by a relative 10.5% from 2010 to 2017 (232.8 vs 260.2 per 100,000, P<0.001 for trend), reported Robert W. Yeh, MD, MSc, of Beth Israel Deaconess Medical Center in Boston, and colleagues in a research letter in JAMA Cardiology.

The sole driver of that decline was a 34.4% drop in elective PCI (from 165.3 to 123.6 per 100,000), which largely occurred in the early part of the study period from 2010 to 2013.

That early shift likely reflected ongoing impact of the 2007 publication of the COURAGE trial, which emphasized the role of medical therapy in managing stable ischemic heart disease by showing that PCI had no outcome advantage.

Since 2013, those rates have stabilized, “potentially owing to waning influence of the trial on clinical practice as well as an increasing population rate of patients with MI undergoing PCI,” Yeh’s group noted.

Urgent PCI rates rose by a relative 15.0% over the entire study period (P<0.001 for trend).

“These patterns mirror what the data and guidelines tell us to do, so that is good to see,” commented Deepak Bhatt, MD, MPH, of Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School in Boston, who was not involved with the study.

More notable were the near doubling in outpatient PCI procedures (from 33.8 to 66.7 per 100,000), while inpatient PCI declined a relative 26.6%.

Since the study period ended in 2017, the proportion of elective PCI done in the outpatient setting has likely increased even more, “and potentially increased substantially,” Yeh told MedPage Today. Medicare started reimbursing elective PCI at freestanding ambulatory surgery centers in 2020.

“In our cath lab, we’ve moved to default outpatient same-day discharge for elective PCIs,” he noted. “I think over the past 5 to 10 years, changes in insurance have both mandated and incentivized outpatient status for PCI as well.”

The shift towards more outpatient PCI has also likely been facilitated by greater adoption of radial artery access, Bhatt added.

“Patients love same-day discharge, and separate data show the safety of this approach in many patients who have undergone elective PCI — especially with use of the radial artery,” he told MedPage Today. “At a time when inpatient hospital beds are often tight, at least at busy centers, same-day discharge also helps with overall patient flow.”

Prior research had suggested a greater overall decline (about 23% vs 10%) in PCIs over the same period, “which is most likely explained by the exclusion of outpatient PCIs in previous studies,” Yeh’s group pointed out.

Their study included both settings by using data from the four states (Florida, Michigan, Maryland, and New York) that mandated 100% of PCI procedures be reported to either their Healthcare Cost and Utilization Project State Inpatient Databases or their State Ambulatory Surgery and Services Databases during the period from January 2010 through December 2017.

These databases captured a total of 1,044,698 PCIs in 333,819 patients (32.0% women, mean age 65.7). Of these procedures, 42.9% were classified as urgent (done for MI) and 57.1% were elective.