Appropriate Use Criteria-Driven Quality Improvement for PCI in Stable Ischemic Heart Disease: A Multimodal Intervention.

backgroundAppropriate use criteria (AUC) for coronary revascularization in patients with stable ischemic heart disease (SIHD) promote guideline-directed medical therapy, objective ischemia testing, and symptom-driven percutaneous coronary intervention (PCI). Despite national improvements, elevated rates of "rarely appropriate" (RA) PCI persist. PROJECT RATIONALE: Benchmarking at a community hospital revealed suboptimal performance on the AUC metric for RA PCI in patients with SIHD, with an average rate of 6.96% and a peak of 12.00%. This reflected gaps in documentation, ischemia assessment, and adequate medical therapy, highlighting the need for a performance improvement initiative. PROJECT SUMMARY: A multimodal intervention was implemented, integrating 4 key components: targeted education on AUC requirements, embedding AUC data fields into precatheterization templates, monthly case reviews, and promoting a "physiology-first" culture, with fractional flow reserve when noninvasive evidence was absent. The primary endpoint was the proportion of elective SIHD PCI cases classified as RA. After implementation, the average RA PCI rate decreased from 6.96% to 0% by the fourth quarter of 2023 and was sustained for 6 consecutive reporting quarters, through the first quarter of 2025. TAKE-HOME MESSAGE: Integrating AUC elements directly into clinical workflows supported by targeted education, a physiology-first approach, and continuous feedback can eliminate RA PCI in SIHD and sustain performance improvement over time.