Normal Coronary Rates for Elective Angiography in the Veterans Affairs Healthcare System: Insights From the VA CART Program (Veterans Affairs Clinical Assessment Reporting and Tracking)

• Published in: Journal of the American College of Cardiology Vol. 63; no. 5; pp. 417 - 426
• Main Authors: BRADLEY, Steven M, MADDOX, Thomas M, STANISLAWSKI, Maggie A, O'DONNELL, Colin I, GRUNWALD, Gary K, TSAI, Thomas T, HO, P. Michael, PETERSON, Eric D, RUMSFELD, John S
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier 11.02.2014
• Subjects: Aged; Biological and medical sciences; Cardiology. Vascular system; Cardiovascular system; Coronary Angiography - utilization; Coronary Disease - diagnostic imaging; Female; Follow-Up Studies; Heart; Hospitals, Veterans - utilization; Humans; Investigative techniques, diagnostic techniques (general aspects); Male; Medical sciences; Medicare - utilization; Middle Aged; Patient Selection; Program Evaluation; Radiodiagnosis. Nmr imagery. Nmr spectrometry; Registries; Retrospective Studies; United States; United States Department of Veterans Affairs; Veterans; United States; North America; America; Health system; Health insurance; Evaluation; Program; Radiodiagnosis; Rate; Cardiovascular disease; Coronary arteriography; Normal; Knowledge; Clinical investigation; Circulatory system; Diagnosis; Veteran; Cardiology; Elective; coronary artery disease; CAD; NCDR; CMS; institutional variability; VA; appropriate use criteria; Clinical Assessment Reporting and Tracking; EHR; AUC; National Cardiovascular Data Registry; Centers for Medicare and Medicaid Services; quality improvement; Veterans Affairs; patient selection; electronic health record; coronary angiography; CART
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2013.09.055

This study sought to determine if an integrated healthcare system is selective and consistent in the use of angiography, as reflected by normal coronary rates. Rates of normal coronary arteries with elective coronary angiography vary considerably among U.S. community hospitals. This variation may in part reflect incentives in fee-for-service care. Using national data from the Veterans Affairs (VA) Clinical Assessment Reporting and Tracking (CART) program representing all 76 VA cardiac catheterization laboratories, we evaluated all patients who underwent elective coronary angiography from October 2007 to September 2010. Normal coronary angiography was defined as <20% stenosis in all vessels. To assess hospital-level variation in normal coronary rates, we categorized hospitals by quartiles as defined by their proportion of normal coronaries. Overall, 4,829 of 22,538 patients (21.4%) had normal coronary angiography. Hospital proportions of normal coronaries varied markedly (median hospital proportion 20.5%; interquartile range: 15.1% to 25.3%; range: 5.5% to 48.5%). Categorized as hospital quartiles, the median proportion of normal coronaries in the lowest quartile was 10.8%, as compared with a median proportion of 19.1% in the second lowest quartile, 23.1% in the second highest quartile, and 30.3% in the highest quartile. Hospitals with lower rates of normal coronaries had higher rates of obstructive coronary disease (59.2% vs. 51.3% vs. 52.6% vs. 44.3%; p < 0.001) and subsequent revascularization (38.1% vs. 33.9% vs. 31.5% vs. 29.3%; p < 0.001). Approximately 1 in 5 patients undergoing elective coronary angiography in the VA had normal coronaries. This rate is lower than prior published studies in other systems. However, the observed hospital-level variation in normal coronary rates suggests opportunities to improve patient selection for diagnostic coronary angiography.