DESCRIPTION (provided by applicant): I intend to improve the care of Veterans with ischemic heart disease (IHD) by reducing inappropriate use of percutaneous coronary interventions (PCIs). PCI is an invasive procedure to reduce blockage in the coronary arteries. In the past decade, PCI use increased by more than 60% to over 1 million PCIs annually in the U.S. despite evidence that PCI offers little or no benefit for many patients, the invasive nature of the procedure incurs risk of serious adverse events, and PCI is expensive. Additionally, there is evidence of 10-fold geographic variation in PCI use. The prevalence, risk, expense, and variation in use of PCI demand methods to guide sensible use of PCI targeted to patients who will benefit. Recently developed appropriate use criteria are intended to guide effective use of PCI. Currently, the overall proportion and regional variation of inappropriate PCI in the VA is unknown. The VA is often presumed to provide more appropriate care than the private sector. However, internal studies suggest that inappropriate use of radiographic imaging parallels the private sector. The VA is now uniquely situated to assess the appropriateness of PCI; determine the patient, provider, and system factors that influence PCI appropriateness; and provide real-time feedback of PCI appropriateness to patients and providers with the intent of improving the appropriateness of PCI performed in VA. The specific aims of this proposal are: Aim 1: To assess the heterogeneity of PCI appropriateness in the VA from data on over 10,000 PCIs and the private sector in Washington State from data on over 14,000 PCIs. Aim 2: To identify patient, provider, and system factors that influence appropriateness of PCI within the VA and private sectors. Aim 3: To evaluate the influence of providing appropriateness ratings to patients and providers in real-time at the point of clinical decision-making on PCI appropriateness. I will achieve my goal of reducing inappropriate use of PCI with the support of a strong mentorship team and the personal acquisition of additional health services research skills. My mentorship team includes nationally recognized health services researchers with expertise in use of the Cardiovascular Reporting and Tracking System-Cath Lab (CART-CL) as a data registry for research and a software platform to improve quality of care, system factors of care, patient health-status, and costs of care. The proposed mentors include: 1) Stephan D. Fihn, MD MPH, Director of VA Northwest HSR&D COE, Research Director of Ischemic Heart Disease-Quality Enhancement Research Initiative (IHD-QuERI) and Co-Director of CART-CL; 2) John S. Rumsfeld, MD PhD, Chief of Cardiology for VA, Clinical Director of IHD-QuERI and Co-Director of CART-CL; 3) John A. Spertus, MD MPH, Clinical Director of Outcomes Research at the Mid America Heart Institute and primary investigator of the center analyzing appropriateness of PCI in the National Cardiovascular Data Registry; and 4) Paul Hebert, PhD, VA Northwest HSR&D COE Investigator, established methodologist and health economist. In addition to this formal mentorship team, Chris L. Bryson, MD MS, VA HSR&D Investigator, and Medical Director of Washington State's Clinical Outcomes Assessment Program for coronary revascularization, will continue to provide mentorship and access to non-VA resources in an active regional quality improvement program for PCI. The mentorship, training, and protected time afforded by this award will ensure my development as an independent investigator improving the judicious use of expensive and invasive approaches in the care of patients with IHD.

Unselective spending and medical use do not achieve the aims of the VA health care system to provide the highest quality care to increase patients' longevity, quality of life, and satisfaction with care. As a result, opportunities exist to ensure therapies are targeted to patients who will benefit and thereby selectively reduce inappropriate services to reduce costs and improve quality of care. Our work will create a mechanism to determine the baseline appropriateness of PCI within the VA and identify the patient, provider, and system factors associated with appropriateness. The proposed research will provide a foundation to develop an intervention to influence the appropriateness of PCI-an invasive and costly procedure for a highly prevalent disease condition in Veterans-and thus have a large impact on the efficiency and quality of health care in VA.