Risk of Demyelinating Diseases in the Central Nervous System in Patients With Inflammatory Bowel Disease Treated With Tumor Necrosis Factor Inhibitors.

stitutions. However, no association was found between hospital reviewof PCI appropriatenesswithprocedural appropriateness, use of guideline-recommended care, or clinical outcomes. TheAUC for coronary revascularization provide patients, health care professionals, payers, and policymakers with an opportunity to critically examineclinical practicepatterns and decisionmaking about patient selection for PCIwith thehope of reducing rates of rarely appropriate PCIs while improving patient outcomes. Our finding that a quarter of hospitals do not conduct reviewsofAUCsuggests thatmanyhospitalshave notprioritized improving their performanceonAUC.Whether the continued incorporation of PCI appropriateness into public reporting and pay-for-performance programs further incentivizes institutional efforts to improvepatient selection for PCI deserves further study. The presence of regular review alonemay be insufficient to improveprocedural appropriateness.Weobserved that differences in institutional PCI appropriateness reviewwere not associatedwithhospitals’ rates of rarely appropriate PCI. This findingmay reflect the fact that the frequencyof appropriateness review is a limited measure of the intensity of an institution’s response to theAUCand the reality that reviewofAUC must be coupled with other enabling structures to be effective. Our survey instrument didnot systematically collect additional details of review, including thenature of appropriateness review (prospective or retrospective) or the specific format of the review process. Consistentwith prior studies,1,6 therewas amodest association between procedural appropriateness and clinical outcomes and a similarly modest correlation between nonacute PCI volume and procedural appropriateness. Of note, hospitalswith ahigher volumeofnonacute PCI had a lower proportion of rarely appropriate PCI across all review frequencies. Whether this finding is related to the presence of better communication, leadership, and oversight at higher-volume PCI centers is unclear. There is a pressing need to identify effective strategies that can be used to support institutional improvement of PCI appropriateness.