The uptake of coronary fractional flow reserve in Australia in the past decade

The use of coronary pressure wires (or fractional flow reserve [FFR]) has been shown to reduce the frequency of major adverse cardiac events and of unnecessary stent procedures, and to lower treatment costs in both the public and private sectors in Australia.1-3 FFR is a tool for assessing physiological ischaemia in coronary artery stenosis, measuring pre- and post-stenosis pressures during adenosine-induced hyperaemia. Because it is evidence-based and quantifiable, it may be discussed during the upcoming Medicare reform. Data on its uptake across Australia, however, have not been published.

We examined trends in FFR use after its addition to the Medicare Benefits Schedule 10 years ago. We analysed Australian Government Department of Human Services data on Medicare items for coronary flow reserve, coronary angiography and percutaneous coronary angiography.

A total of 14 160 FFR services were processed by Medicare during the past 10 years. FFR use grew during this period, with a mean annual increase of 55%, from 131 services in 2007 to 3869 in 2015 (non-parametric analysis, P = 0.004). Time series analysis identified a Gompertz non-linear trend of FFR against time, indicating that national FFR use is continuing to increase, although growth began to slow in 2014. Further, FFR use increased on a population basis by an average of 45% each year, from 1 per 100 000 in 2007 to 16 per 100 000 in 2015, when these figures were highest in New South Wales (23 per 100 000) and Queensland (19 per 100 000) (Box).

The national rate of FFR per coronary angiogram increased from 0.02% in 2006 to 4.8% in 2015 (P = 0.004), when the highest rate was in NSW (5.8%). The rate of FFR per percutaneous coronary intervention (PCI) increased from 0.1% in 2006 to 19.2% in 2015 (P = 0.004), when the highest rate was in Queensland (26.6%). In 2015, there were 5.2 PCIs per FFR used; the rate was not related to the population size of the state or territory (Spearman non-parametric correlation, ρ_S = 0.07; P = 0.87) or to total PCI use (ρ_S = 0.12, P = 0.78). There was marked variation between states and territories (Box), highlighting heterogeneity across Australia in the use of FFR.

The data summarised in the Box allow operators and hospitals to compare their use of FFR with state and national averages, and they facilitate more standardised care across Australia. Barriers to the uptake of FFR include operator and centre experience, availability and cost. It has been suggested that FFR is discouraged by the lower remuneration received if stenting is not performed.4 From a national perspective, however, there is a mean saving of $1200 per patient in the public sector and $5000 per patient in the private sector when FFR makes stenting unnecessary,2 representing a total annual saving of $4 million.4

The use of FFR across Australia is heterogeneous, but it has grown over the past decade, both in absolute numbers and as proportions of coronary angiograms and PCI.