Introduction

Chronic coronary syndrome (CCS) has a high prevalence and incidence in Germany and the current guidelines on CCS give clear recommendations for the stratification and algorithmic use of non-invasive and invasive diagnostic modalities. For Germany there is growing evidence for a guideline-non-adherent overuse of coronary angiographies (CAG) in patients with suspected CCS with an underuse of non-invasive imaging guided testing (NIGT) (stress-echo, coronary CT-angiography, myocardial perfusion scintigraphy and stress magnetic resonance tomography). This health claims data (HCD) based analysis aims to give an overview in the use of NIGT prior to CAG in patients with suspected CCS being insured by the statutory health insurance company “AOK Rheinland/Hamburg”.

Methods

AOK Rheinland/Hamburg HCD from the year 2019 were retrospectively analyzed. Relevant invasive and non-invasive test were identified using the uniform German health insurance billing codes for in- and outpatient procedures. The diagnosis was identified by the corresponding ICD-10-codes. In addition, all health care providers (HCP) performing at least two CAG in AOK Rhineland/Hamburg insurees per month were identified. The final cohort consisted of all AOK Rhineland/Hamburg insurees who underwent at least one CAG in 2019 for suspected CCS, and if conducted the performance of NIGT in the 3 months prior to CAG. In this cohort a benchmarking-analysis regarding differences between HCP (with at least two CAG per month) in the use of NIGT prior to CAG in patients with suspected CCS was conducted. Results were adjusted for the patient characteristics age and sex, as well as the HCP annual CAG volume, proportion of CAG for acute myocardial infarction (AMI) and proportion of revascularization.

Results

In 2019 a total of 8599 CAG were performed by a total of 241 HCP in patients with suspected CCS. The benchmarking was limited to 7885 CAG performed by the 82 HCP with at least two CAG per month.

In these centers in mean 319 AOK Rhineland/Hamburg insurees underwent CAG for the indication of an AMI in 29,3%, unstable angina in 29,6% and CCS in 28,7%. Revascularization of any kind was performed 15,9% of cases, with PCI in 89,6% and a coronary artery bypass graft operation in 11,1%. In suspected CCS NIGT in the 3 months prior to CAG was performed in 6,0%. In 12 of the 82 HCP the rate of CAG with prior NIGT was significantly above average. In multivariate analyses neither age, sex, annual volume of CAG, the proportion of CCS of all CAG nor the proportion of AMI treated by the HCP did reveal a significant correlation to the rate of prior NIGT. With regard to revascularizations the overall rate of prior NIGT was 7,6 %. 3 out of 82 health care providers performed significantly above the average in employing NIGT prior to CAG.

Conclusions

The analyzed data reveal a very low use of NIGT prior to CAG in patients with suspected CCS in the 2019 real-world practice in Rhineland and Hamburg. In the 82 centers only 6,0% of the CCS patients underwent NIGT prior to CAG. The overall revascularisation rate in patients with suspected CCS was 15,9 %. Of note, only by 12 of the 82 HCP NIGT prior to CAG was performed significantly above average.

In summary, these data clearly address the need to strengthen the role of NIGT for patients with suspected CCS in the German health care system, while certain HCP might serve as best-practice examples on how to increase the use of NIGT.