Upcoding of Clinical Information to Meet Appropriate Use Criteria for Percutaneous Coronary Intervention
2019; Lippincott Williams & Wilkins; Volume: 12; Issue: 3 Linguagem: Inglês
10.1161/circoutcomes.118.005025
ISSN1941-7705
AutoresChristopher Rajkumar, William Suh, Dárrel P. Francis,
Tópico(s)Antiplatelet Therapy and Cardiovascular Diseases
ResumoHomeCirculation: Cardiovascular Quality and OutcomesVol. 12, No. 3Upcoding of Clinical Information to Meet Appropriate Use Criteria for Percutaneous Coronary Intervention Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessArticle CommentaryPDF/EPUBUpcoding of Clinical Information to Meet Appropriate Use Criteria for Percutaneous Coronary Intervention Christopher A. Rajkumar, MBBS, BSc, MRCP, William M. Suh, MD, FSCAI and Darrel P. Francis, MD, MRCP Christopher A. RajkumarChristopher A. Rajkumar International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., D.P.F.). , William M. SuhWilliam M. Suh Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles (W.M.S.). and Darrel P. FrancisDarrel P. Francis Darrel P. Francis, MD, International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59–61 N Wharf Rd, London W2 1LA, United Kingdom. Email E-mail Address: [email protected] International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., D.P.F.). Originally published15 Mar 2019https://doi.org/10.1161/CIRCOUTCOMES.118.005025Circulation: Cardiovascular Quality and Outcomes. 2019;12:e005025This article is commented on by the following:Policing or Learning?See Editorial by Rao et alA reason to disregard ORBITA1 in the United States, according to some key opinion leaders is the startlingly high proportion of percutaneous coronary intervention (PCI) that is performed for unstable coronary disease in the United States by comparison to peers. In the United States, 82% of PCIs are reported to be performed in emergency or unstable situations2 in comparison to approximately 65% in the United Kingdom3 and, closer to home, 59% in the province of Ontario, Canada.4 In this article, we look for evidence of so-called "gaming" or "upcoding" in which coronary disease becomes rated as more acute.Appropriate use criteria (AUC) for coronary revascularization seek to inhibit unnecessary procedures,5 but there are in fact 2 ways a physician can become compliant. One is to do fewer unnecessary procedures, and the other is to make unnecessary procedures seem necessary. This is much easier to do than many nonphysicians appreciate.Instability Is in the Eye of the BeholderAUC make a sharp distinction between stable angina which arises predictably on exertion and unstable angina which is rapidly escalating in intensity or occurring at rest.In medical school, these seem to be easy to distinguish. On the one hand is a patient attending an outpatient clinic because of angina on walking up hills. On the other is a patient confined to the hospital bed because of episodes of rest pain, perhaps with dynamic ECG changes during the pain. We know the latter group stand to gain from early PCI.However, unlike many cardiological assessments we make, there is no diagnostic test to confirm or refute unstable angina. As a result, the clinician is free to judge whether a patient's angina is unstable or not.Infectious InstabilityPatients, too, have to make decisions, for example, whether sensations do indeed fall into the category of "pain." They already know that pain is more concerning in the chest than elsewhere. Seeing a cardiologist can have a transformative effect on the symptom experienced and its instability. This impact is at 3 levels: knowledge, attitude, and behavior.6At the simple knowledge level, the doctor reassures the patient that medication is the key to preventing stable coronary disease from turning into a serious event. However, the explicitly verbalized facts are only a small part of what is communicated.More importantly, we simultaneously convey an attitude of concern, by asking detailed questions about the symptom which a blinded third party might rate as atypical but in light of ischemia tests gradually crystallizes around textbook patterns of angina.Finally, our consultation ends with the behavior of arranging an angiogram as soon as possible. No wonder patients feel that PCI for stable angina is necessary to save their lives,7 even though no cardiologist has said this to them at the knowledge level.The 2010 Experiment of NatureThis complex process of judgment has existed since time immemorial. What has changed recently is the external influence on the process.Although there have been guidelines for some years, it was in 2010 that PCI appropriateness assessments began in hospitals in the United States, ie, assessments made automatically based on data provided by the individual physician operators.8 Some states have sought to reduce misuse, control costs, and improve compliance with AUC.8,9 For 2 states, New York9 and Washington,8 annual data around this time are in the public domain, broken down by physician reported category (stable or unstable).New York state has gone so far as to consider linking Medicaid reimbursement to AUC adherence.9 Ontario, the Canadian province geographically adjacent to New York but not exposed to the regulatory effect of AUC, has also provided equivalent data.4We used these data sources to assess the changing indications for PCI following the publication of AUC. A description of each data source is supplied in Appendix I in the Data Supplement.Acute PCI Growing in Dominance in the United StatesWith each passing year following the introduction of AUC in 2009, both New York and Washington saw a progressive annual increase in the proportion of all PCI that was performed for acute coronary syndromes (Figure 1).8,9Download figureDownload PowerPointFigure 1. The annual proportion of percutaneous coronary intervention (PCI) performed for stable coronary artery disease and acute coronary syndromes in New York and Washington states and the province of Ontario, Canada, since the application of appropriate use criteria (AUC) in the United States in 2009.In the adjacent province of Ontario, there was no such secular increase in the proportion of PCI that was performed for acute coronary syndromes.4 In fact, over the same time interval, this proportion even saw a modest fall.Four- to 10-Fold Larger Increase in Acute PCIBefore the implementation of AUC feedback, the per capita rate of acute PCI in New York was 68.2% higher than in Ontario. In Washington, it was 33.1% higher than in Ontario. Over the next 4 years, New York rose to 84% above Ontario and Washington to 38.1% above Ontario (Figure 2).Download figureDownload PowerPointFigure 2. Annual numbers of percutaneous coronary intervention (PCI) performed for acute coronary syndromes (ACS) per million population in New York and Washington states as well as Ontario, Canada. The shaded areas indicate the unexpected increase in numbers of PCI for ACS performed in New York and Washington following PCI appropriateness assessments initiated in 2010.Absolute rates of acute PCI procedures had escalated by 197 per million in New York and 78 per million in Washington, respectively 10 and 4 times larger than the absolute increase in Ontario, 19 per million.Changes in Documented Angina Score in Patients Undergoing PCI for Stable Coronary Disease Following AUCEven within stable angina, physician interpretation is required to judge the severity of symptoms. During these transition years, there was a dramatic increase in the intensity of stable angina reported by physicians (Figure 3A). This can be viewed from data across the whole of the United States, between 2009 and 2014, covering 397 737 procedures.2Download figureDownload PowerPointFigure 3. Non-acute percutaneous coronary intervention (PCI) in the United States. Documented patient-reported symptoms (A) and angiographic disease (B), in patients undergoing elective PCI for stable coronary artery disease across the United States. CCS indicates Canadian Cardiovascular Society.This pan-US data demonstrates a doubling of the rate of Canadian Cardiovascular Society 3 (angina on mild effort) and Canadian Cardiovascular Society 4 (angina at rest) reported in those undergoing PCI for stable coronary disease following the publication of AUC. In 2009, the proportion of patients with Canadian Cardiovascular Society 3 or 4 angina was just 15.8%. By 2014, this proportion had more than doubled to 38.4%. The excess number of patients experiencing Canadian Cardiovascular Society 3 or 4 angina in 2014 by comparison to 2009 was 9837 patients per year.Such dramatic changes in reported symptomatology over such a short timespan render a biological cause improbable. Certainly, this was not caused by a worsening pattern of coronary disease over time. The chart of number of diseased vessels shows only a miniscule trend to worsening; with the proportion of patients having 2 or 3 vessel disease rising only from 42.7% to 47.5% (Figure 3B).Is This Upcoding?There was a 4- to 10-fold greater increase in population rates of PCI for acute coronary syndromes in the AUC states following the onset of appropriateness assessments. Simultaneously, patients with stable disease showed a dramatic rise of high-grade angina symptoms, disproportionate to the minimal secular trend in coronary anatomy. These 2 findings are difficult to explain by biological processes alone.Upcoding encompasses a wide spectrum of behaviors ranging from fraud, claiming payments for untruthful diagnoses or treatments, to a subtle bias towards one diagnostic interpretation rather than another. The benign end of the spectrum exists because the boundary between diagnostic categories is blurred, with many patients fitting 2 or more categories.A similar analysis has identified a dramatic rise in the volume of outpatient PCI that was categorized as acute following AUC.10 The National Cardiovascular Data Registry provides an undemanding definition of unstable angina which is simple to fulfill.11 But why procedures for unstable angina continued to increase, year-on-year following AUC, in the face of high sensitivity troponin assays, remains unexplained. Our analysis adds to this data, demonstrating a concordant and progressive rise in high-grade angina in those undergoing PCI for stable disease.Formal confirmation of the magnitude of upcoding could be obtained by a randomized controlled trial in which at sometimes physicians were incentivized to make one diagnosis and at other times, another. No such trial has been performed. Moreover, since the physicians being trialed would have to give informed consent, they would know what was being tested and could easily influence the result. For this reason, large scale observational data may be the current best evidence on this question.Major effort has recently been put into standardized documentation of symptoms (sometimes called Patient-Reported Outcome Measures) using the Seattle Angina Questionnaire and the Rose Dyspnea Scale. However, these are applied after contact with a cardiologist who has recommended PCI. During such a consultation, it is inevitable that emphasis will be placed on symptoms because the doctor and patient expect these to be improved by the procedure. Therefore, although the documentation may become more standardized, this may simply standardize the inclusion of bias rather than remove it.Nor does the substantial effort put into the assessment of postprocedural symptoms eliminate the placebo effect. Patients filling out the questionnaires have invested personal risk which, through the principal of cognitive dissonance, increases the likelihood of reporting benefit.Upcoding or Consensus Building?The upcoding we observe is fundamentally not a malicious process. It represents doctors and patients sharing the simple and common-sense idea that tight coronary lesions are undesirable and should be treated with stents. Starting from that premise, the doctor and patient build a consensus so that care can go forwards rather than moving in circles of doubt. This consensus building process naturally includes discussing advantages of the procedure for symptom relief, even though the true reason many patients undergo PCI for stable coronary artery disease is that they and their doctors do not like the idea of leaving those lesions alone.Our community and our patients would benefit if we accepted this fact and discussed it openly. The only way to truthfully understand why procedures are done is to not restrict their performance to patients with specific conditions.LimitationsIndividual state data separating stable from acute PCI is only publicly available for a few states. There is nationwide data,2 but this is the sum of many states, each of which can have a different timing of enforcement of AUC, precluding any possibility of detecting a temporal match in the aggregate data.Upcoding is only one component of the change in proportions of acute versus stable PCI in the United States. Much of this shift is likely to be because of genuinely more conservative handling of stable coronary artery disease since AUC. Indeed, there has been a definite nationwide fall in PCI overall of 15% from 2010 to 2014, which represents more judicious care overall and not upcoding.2It is possible that prompting by modern electronic health record systems ensures that key symptom information suggesting instability is collected more systematically now than previously, which would cause a tilt towards categorization as acute. However, this would have to be an electronic health record trend only on the south side of the border with Canada.Our interpretation of the data has important limitations. First, we have not attempted to adjust for differences between the countries in demographic trends that may cause plaque instability. However, the size of such divergence is limited by the geographic proximity of the neighboring regions. Second, the Canadian hub-and-spoke model may be more restrictive of the provision of PCI than the fee-for-service model employed in the United States.Third, we have addressed these 2 US states because they have implemented policies and published their data. Action chosen by different states may have different effect sizes and different time courses. Therefore, even if the effects are in the same direction, the national total will experience an effect which is not sharply localized in time but smeared out over years. On a background of generally falling age-adjusted rates of atherosclerosis,12 this would manifest as an enhancement of the downtrend in stable PCI and an attenuation of a downtrend in acute PCI. If the strength and progressiveness of the upcoding effect were just right the rates of acute PCI could hold almost constant while the stable PCI rate plummets.Perhaps by chance, this is the pattern seen across the United States as a whole.2 Whether this is the mechanism is a testable hypothesis since such a mechanism would last only as long as rates of upcoding can continue to increase. Once reported stable PCI bottoms out, we hypothesize that reported acute PCI, now including everyone that can be upcoded, will return to tracking the underlying downtrend.Significance for Policy Makers, Patients, and ResearchersThe lesson from upcoding is that if trying to restrain free enterprise in a fee-for-service system, it is insufficient to impose a gatekeeper function depending on clinical judgment of the same physicians in whom one is trying to curtail unnecessary activity. An elaborate solution might be a system of independent review of the patient before the patient has had contact from a cardiologist who may bias their description of their symptoms. Simpler might be to remove the financial incentive to perform more procedures.Upcoding can harm patients by facilitating unnecessary PCI, but also by misrepresenting to the patient the nature of their cardiac diagnosis. Moreover, researchers analyzing registries of data in which upcoding is embedded will unintentionally produce a distorted picture in their publications.ConclusionsObservations of geographic differences in trends of procedure rates, and the discrepancy between the time trends of symptoms and extent of coronary disease, are consistent with (but not proof of) a rise in upcoding around the time of introduction of reporting of adherence to AUC. There may never be a better test of the upcoding response to regulatory attempts to curb free enterprise in healthcare. We should face up to the fact that as a community, we find it difficult to accept that stable coronary stenoses need not be stented. Evidence of this difficulty is that we cannot resist the temptation to hunt these coronary stenoses down.If we ever doubt the fundamental problem of which upcoding is a symptom, we only need to ask ourselves why there is not a corresponding problem of "downcoding."DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.The Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCOUTCOMES.118.005025.Darrel P. Francis, MD, International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59–61 N Wharf Rd, London W2 1LA, United Kingdom. Email [email protected]orgReferences1. 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Circulation: Cardiovascular Quality and Outcomes. 2019;12 March 2019Vol 12, Issue 3 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.118.005025PMID: 30871374 Originally publishedMarch 15, 2019 Keywordsguideline adherencepercutaneous coronary interventioncoronary artery diseasePDF download Advertisement SubjectsCardiovascular DiseasePercutaneous Coronary InterventionRevascularization
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