Real-World Predictors and Temporal Trends in Intravascular Imaging Use During Percutaneous Coronary Intervention in a Publicly Funded Health System

BACKGROUND Intravascular imaging (IVI) improves clinical outcomes in percutaneous coronary intervention (PCI), yet real-world utilisation remains inconsistent. We evaluated temporal trends and determinants of IVI use within a large publicly funded, non-fee-for-service, healthcare system. METHODS All PCI procedures performed across Queensland public hospitals between 2016 and 2023 were analysed using registry data. The primary outcome was IVI use. Independent predictors were assessed using multivariable analysis. RESULTS Among 39,136 PCI procedures, IVI was used in 9.0% overall and increased from 5.6% in 2016 to 16.5% in 2023 (ptrend=0.002). Procedural complexity was the primary determinant: left main PCI (adjusted odds ratio [aOR] 7.84; 95% confidence interval [CI] 5.26-11.69), intravascular lithotripsy (aOR 8.51; 95% CI 3.78-19.15), and bifurcation lesions (aOR 1.34; 95% CI 1.01-1.78) were independent predictors. Conversely, ST-elevation myocardial infarction predicted lower use (aOR 0.49; 95% CI 0.42-0.59). Higher operator procedural volume was associated with increased IVI use (aOR 1.25; 95% CI 1.00-1.54). While operator training era and institutional factors were significant in unadjusted models, associations were attenuated after accounting for hospital-level clustering, suggesting strong influence of local hospital processes and culture toward IVI. CONCLUSIONS IVI use has increased but remains underutilised. Adoption is driven primarily by procedural complexity and operator-level factors, with persistent inter-hospital variability. These findings highlight an ongoing evidence-practice gap and support system-level strategies to standardise IVI use in contemporary PCI.