Moving from volume to value for revascularization in stable ischemic heart disease: A review

Importance: Although percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are both commonly employed in the treatment of stable ischemic heart disease (SIHD), their ability to reduce subsequent heart attacks and death is currently in question. These procedures will come under increasing scrutiny as the healthcare reimbursement system moves away from the traditional fee for service model in favor of “pay for value”. Observation: Both international and domestic data show wide variability in the use of PCI and CABG in patients with SIHD. There is evidence of ongoing quality improvement over the last 5 years in reducing the use of inappropriate procedures, but there is still room for improvement. We present ideas regarding health policy interventions that might help manage the transition to value-based payments in this area, including improvements in national registries, more rapid revision of appropriate use criteria, shared decision making, and evidence-based management of PCI in SIHD. Conclusions and Relevance: The use of revascularization procedures in patients with SIHD is potentially a model for how care might be improved with health care policy intervention. We suggest that the status quo, although apparently improved over the last 5 years, is still unacceptable when 25% of hospitals have a rate of unnecessary PCI in patients with SIHD that approaches 25%.