1
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Sasaki K, Koeda Y, Yoshizawa R, Ishikawa Y, Ishida M, Itoh T, Morino Y, Saitoh H, Onodera H, Nozaki T, Maegawa Y, Nishiyama O, Ozawa M, Osaki T, Nakamura A. Comparing In-Hospital Outcomes for Acute Myocardial Infarction Patients in High-Volume Hospitals Performing Primary Percutaneous Coronary Intervention vs. Regional General Hospitals. Circ J 2023; 87:1347-1355. [PMID: 37558468 DOI: 10.1253/circj.cj-23-0188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
BACKGROUND It has been reported that patients with acute myocardial infarction (AMI) transferred to low-volume primary percutaneous coronary intervention (PCI) hospitals (<115/year) in low population density areas experience higher in-hospital mortality rates. This study compared in-hospital outcomes of patients admitted to high-volume primary PCI hospitals (≥115/year) with those for other regional general hospitals.Methods and Results: Retrospective analysis was conducted on data obtained from 2,453 patients with AMI admitted to hospitals in Iwate Prefecture (2014-2018). Multivariate analysis revealed that the in-hospital mortality rate of AMI among patients in regional general hospitals was significantly higher than among patients in high-volume hospitals. However, no significant difference in mortality rate was observed among patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI. Although no significant difference was found in the in-hospital mortality rate of patients with Killip class I STEMI, significantly lower in-hospital mortality rates were observed in patients admitted in high-volume hospitals for Killip classes II, III, and IV. CONCLUSIONS Although in-hospital outcomes for patients with STEMI undergoing primary PCI were similar, patients with heart failure or cardiogenic shock exhibited better in-hospital outcomes in high-volume primary PCI hospitals than those in regional general hospitals.
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Affiliation(s)
- Koto Sasaki
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Yorihiko Koeda
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Reisuke Yoshizawa
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Yuh Ishikawa
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Masaru Ishida
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Tomonori Itoh
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | | | | | - Tetsuji Nozaki
- Department of Cardiology, Iwate Prefectural Isawa Hospital
| | - Yuko Maegawa
- Department of Cardiology, Iwate Prefectural Miyako Hospital
| | | | - Mahito Ozawa
- Department of Cardiology, Japanese Red Cross Morioka Hospital
| | - Takuya Osaki
- Department of Cardiology, Iwate Prefectural Kuji Hospital
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2
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Nogueira RG, Haussen DC, Smith EE, Sun JL, Xian Y, Alhanti B, Blanco R, Mac Grory B, Doheim MF, Bhatt DL, Fonarow GC, Hassan AE, Joundi RA, Mocco J, Frankel MR, Schwamm LH. Higher Procedural Volumes Are Associated with Faster Treatment Times, Better Functional Outcomes, and Lower Mortality in Patients Undergoing Endovascular Treatment for Acute Ischemic Stroke. Ann Neurol 2023. [PMID: 37731004 DOI: 10.1002/ana.26803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/22/2023] [Accepted: 09/18/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE We aimed to characterize the association of hospital procedural volumes with outcomes among acute ischemic stroke (AIS) patients undergoing endovascular therapy (EVT). METHODS This was a retrospective, observational cohort study using data prospectively collected from January 1, 2016 to December 31, 2019 in the Get with the Guidelines-Stroke registry. Participants were derived from a cohort of 60,727 AIS patients treated with EVT within 24 hours at 626 hospitals. The primary cohort excluded patients with pretreatment National Institutes of Health Stroke Scale (NIHSS) < 6, onset-to-treatment time > 6 hours, and interhospital transfers. There were 2 secondary cohorts: (1) the EVT metrics cohort excluded patients with missing data on time from door to arterial puncture and (2) the intravenous thrombolysis (IVT) metrics cohort only included patients receiving IVT ≤4.5 hours after onset. RESULTS The primary cohort (mean ± standard deviation age = 70.7 ± 14.8 years; 51.2% female; median [interquartile range] baseline NIHSS = 18.0 [13-22]; IVT use, 70.2%) comprised 21,209 patients across 595 hospitals. The EVT metrics cohort and IVT metrics cohort comprised 47,262 and 16,889 patients across 408 and 601 hospitals, respectively. Higher procedural volumes were significantly associated with higher odds (expressed as adjusted odds ratio [95% confidence interval] for every 10-case increase in volume) of discharge to home (1.03 [1.02-1.04]), functional independence at discharge (1.02 [1.01-1.04]), and lower rates of in-hospital mortality (0.96 [0.95-0.98]). All secondary measures were also associated with procedural volumes. INTERPRETATION Among AIS patients primarily presenting to EVT-capable hospitals (excluding those transferred from one facility to another and those suffering in-hospital strokes), EVT at hospitals with higher procedural volumes was associated with faster treatment times, better discharge outcomes, and lower rates of in-hospital mortality. ANN NEUROL 2023.
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Affiliation(s)
- Raul G Nogueira
- Departments of Neurology and Neurosurgery, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Diogo C Haussen
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Mohamed F Doheim
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ameer E Hassan
- University of Texas Rio Grande Valley-Valley Baptist Medical Center, Harlingen, TX, USA
| | - Raed A Joundi
- Division of Neurology, Hamilton Health Sciences, McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael R Frankel
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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3
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Larsen AI, Løland KH, Hovland S, Bleie Ø, Eek C, Fossum E, Trovik T, Juliebø V, Hegbom K, Moer R, Larsen T, Uchto M, Rotevatn S. Guideline-Recommended Time Less Than 90 Minutes From ECG to Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction Is Associated with Major Survival Benefits, Especially in Octogenarians: A Contemporary Report in 11 226 Patients from NORIC. J Am Heart Assoc 2022; 11:e024849. [PMID: 36056722 PMCID: PMC9496403 DOI: 10.1161/jaha.122.024849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Using contemporary data from NORIC (Norwegian Registry of Invasive Cardiology) we investigated the predictive value of patient age and time from ECG diagnosis to sheath insertion (ECG‐2‐sheath) in primary percutaneous coronary intervention for ST‐segment–elevation myocardial infarction (STEMI). Methods and Results Data from 11 226 patients collected from all centers offering 24/7/365 primary percutaneous coronary intervention service were explored. For patients aged <80 years the mortality rates were 5.6% and 7.6% at 30 days and 1 year, respectively. For octogenarians the corresponding rates were 15.0% and 24.2%. The Cox hazard ratio was 2.02 (1.93–2.11, P value <0.0001) per 10 years of patient age. Time from ECG‐2‐sheath was significantly associated with mortality with a 3.6% increase per 30 minutes of time. Using achievement of time goal <90 minutes in patients aged >80 years and mortality at 30 days, mortality was 10.5% and 17.7% for <90 or ≥90 minutes, respectively. The number needed to prevent 1 death was 39 in the whole population and 14 in the elderly. Restricted mean survival gains during median 938 days of follow‐up in patients with ECG‐2‐sheath time <90 minutes were 24 and 76 days for patients aged <80 and ≥80 years, respectively. Conclusions Time from ECG‐diagnosis to sheath insertion is strongly correlated with mortality. This applies especially to octogenarians who derive the most in terms of absolute mortality reduction. Registration URL: https://helsedata.no/en/forvaltere/norwegian‐institute‐of‐public‐health/norwegian‐registry‐of‐invasive‐cardiology/.
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Affiliation(s)
- Alf Inge Larsen
- Department of Cardiology Stavanger University Hospital Stavanger Norway.,Institute of Clinical Sciences, University of Bergen Bergen Norway
| | - Kjetil Halvorsen Løland
- Norwegian Registry of Invasive Cardiology (NORIC) Haukeland University Hospital Bergen Norway.,Department of Heart Disease Haukeland University Hospital Bergen Norway
| | - Siren Hovland
- Norwegian Registry of Invasive Cardiology (NORIC) Haukeland University Hospital Bergen Norway
| | - Øyvind Bleie
- Department of Heart Disease Haukeland University Hospital Bergen Norway
| | - Christian Eek
- Department of Cardiology Oslo University Hospital, Rikshospitalet Oslo Norway
| | - Eigil Fossum
- Department of Cardiology Oslo University Hospital Ullevål, Oslo Norway
| | - Thor Trovik
- Department of Cardiology University Hospital of North Norway Tromsø Norway
| | - Vibeke Juliebø
- Department of Cardiology Akershus University Hospital Lørenskog Norway
| | - Knut Hegbom
- Clinic for Heart Disease St. Olav's University Hospital Trondheim Norway
| | | | | | - Michael Uchto
- Division of Internal Medicine Nordlandssykehuset Bodø Norway
| | - Svein Rotevatn
- Norwegian Registry of Invasive Cardiology (NORIC) Haukeland University Hospital Bergen Norway
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4
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Kovach CP, O'Donnell CI, Swat S, Doll JA, Plomondon ME, Schofield R, Valle JA, Waldo SW. Impact of operator volumes and experience on outcomes after percutaneous coronary intervention: Insights from the Veterans Affairs Clinical Assessment, Reporting and Tracking (CART) program. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:64-68. [PMID: 34774419 DOI: 10.1016/j.carrev.2021.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recent analyses of the volume-outcome relationship for percutaneous coronary intervention (PCI) have suggested a less robust association than previously reported. It is unknown if novel factors such as lifetime operator experience influence this relationship. OBJECTIVES To assess the relationship between annual volumes and outcomes for PCI and determine whether lifetime operator experience modulates the association. METHODS Annual PCI volumes for facilities and operators within the Veterans Affairs Healthcare System and their relationship with 30-day mortality following PCI were described. The influence of operator lifetime experience on the volume-outcome relationship was assessed. Hierarchical logistic regression was used to adjust for patient and procedural factors. RESULTS 57,608 PCIs performed from 2013 to 2018 by 382 operators and 63 institutions were analyzed. Operator annualized PCI volume averaged 47.6 (standard deviation [SD] 49.1) and site annualized volume averaged 189.2 (SD 105.2). Median operator experience was 9.0 years (interquartile range [IQR] 4.0-15.0). There was no independent relationship between operator annual volume, institutional volume, or operator lifetime experience with 30-day mortality (p > 0.10). However, the interaction between operator volume and lifetime experience was associated with a marginal decrease in mortality (odds ratio [OR] 0.9998, 95% CI 0.9996-0.9999). CONCLUSIONS There were no significant associations between facility or operator-level procedural volume and 30-day mortality following PCI in a nationally integrated healthcare system. There was a marginal association between the interaction of operator lifetime experience, operator annual volume, and 30-day mortality that is unlikely to be clinically relevant, though does suggest an opportunity to explore novel factors that may influence the volume-outcome relationship.
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Affiliation(s)
- Christopher P Kovach
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO, United States of America
| | - Colin I O'Donnell
- Department of Medicine, Rocky Mountain VA Medical Center, Aurora, CO, United States of America; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC, United States of America
| | - Stanley Swat
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO, United States of America
| | - Jacob A Doll
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States of America; Department of Medicine, Puget Sound VA Medical Center, Seattle, WA, United States of America
| | - Mary E Plomondon
- Department of Medicine, Rocky Mountain VA Medical Center, Aurora, CO, United States of America; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC, United States of America
| | - Richard Schofield
- University of Florida College of Medicine, Gainesville, FL, United States of America; Department of Veterans Affairs Medical Center, Gainesville, FL, United States of America
| | - Javier A Valle
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO, United States of America; Michigan Heart and Vascular Institute, Ann Arbor, MI, United States of America
| | - Stephen W Waldo
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO, United States of America; Department of Medicine, Rocky Mountain VA Medical Center, Aurora, CO, United States of America; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC, United States of America.
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5
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Khera R, Liu Y, de Lemos JA, Das SR, Pandey A, Omar W, Kumbhani DJ, Girotra S, Yeh RW, Rutan C, Walchok J, Lin Z, Bradley SM, Velazquez EJ, Churchwell KB, Nallamothu BK, Krumholz HM, Curtis JP. Association of COVID-19 Hospitalization Volume and Case Growth at US Hospitals with Patient Outcomes. Am J Med 2021; 134:1380-1388.e3. [PMID: 34343515 PMCID: PMC8325555 DOI: 10.1016/j.amjmed.2021.06.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Whether the volume of coronavirus disease 2019 (COVID-19) hospitalizations is associated with outcomes has important implications for the organization of hospital care both during this pandemic and future novel and rapidly evolving high-volume conditions. METHODS We identified COVID-19 hospitalizations at US hospitals in the American Heart Association COVID-19 Cardiovascular Disease Registry with ≥10 cases between January and August 2020. We evaluated the association of COVID-19 hospitalization volume and weekly case growth indexed to hospital bed capacity, with hospital risk-standardized in-hospital case-fatality rate (rsCFR). RESULTS There were 85 hospitals with 15,329 COVID-19 hospitalizations, with a median hospital case volume was 118 (interquartile range, 57, 252) and median growth rate of 2 cases per 100 beds per week but varied widely (interquartile range: 0.9 to 4.5). There was no significant association between overall hospital COVID-19 case volume and rsCFR (rho, 0.18, P = .09). However, hospitals with more rapid COVID-19 case-growth had higher rsCFR (rho, 0.22, P = 0.047), increasing across case growth quartiles (P trend = .03). Although there were no differences in medical treatments or intensive care unit therapies (mechanical ventilation, vasopressors), the highest case growth quartile had 4-fold higher odds of above median rsCFR, compared with the lowest quartile (odds ratio, 4.00; 1.15 to 13.8, P = .03). CONCLUSIONS An accelerated case growth trajectory is a marker of hospitals at risk of poor COVID-19 outcomes, identifying sites that may be targets for influx of additional resources or triage strategies. Early identification of such hospital signatures is essential as our health system prepares for future health challenges.
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Affiliation(s)
- Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn.
| | - Yusi Liu
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
| | - James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
| | - Sandeep R Das
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
| | - Wally Omar
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Dharam J Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
| | - Saket Girotra
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Robert W Yeh
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass; Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Mass
| | | | | | - Zhenqiu Lin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
| | - Steven M Bradley
- Healthcare Delivery Innovation Center, Minneapolis Heart Institute, Minn
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Keith B Churchwell
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | | | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn; Department of Health Policy and Management, Yale School of Public Health, New Haven, Conn
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
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6
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Warren AF, Rosner C, Gattani R, Truesdell AG, Proudfoot AG. Cardiogenic Shock: Protocols, Teams, Centers, and Networks. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The mortality of cardiogenic shock (CS) remains unacceptably high. Delays in the recognition of CS and access to disease-modifying or hemodynamically stabilizing interventions likely contribute to poor outcomes. In parallel to successful initiatives in other disease states, such as acute ST-elevation MI and major trauma, institutions are increasingly advocating the use of a multidisciplinary ‘shock team’ approach to CS management. A volume–outcome relationship exists in CS, as with many other acute cardiovascular conditions, and the emergence of ‘shock hubs’ as experienced facilities with an interest in improving CS outcomes through a hub-and-spoke ‘shock network’ approach provides another opportunity to deliver improved CS care as widely and equitably as possible. This narrative review outlines improvements from a networked approach to care, discusses a team-based and protocolized approach to CS management, reviews the available evidence and discusses the potential benefits, challenges, and opportunities of such systems of care.
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Affiliation(s)
- Alex F Warren
- South-East Scotland School of Anaesthesia, Edinburgh, UK; Anaesthesia, Critical Care and Pain, University of Edinburgh, Edinburgh, UK
| | | | | | - Alex G Truesdell
- Inova Heart and Vascular Institute, Falls Church, VA; Virginia Heart, Falls Church, VA
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, London, UK; Clinic for Anaesthesiology and Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany; Department of Anaesthesiology and Intensive Care, German Heart Centre Berlin, Berlin, Germany; Queen Mary University of London, London, UK
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7
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Isogai T, Saad AM, Michihata N, Ahuja KR, Shekhar S, Abdelfattah OM, Kaur M, Gad MM, Svensson LG, Kapadia SR. Association of hospital procedural volume with incidence and outcomes of surgical bailout in patients undergoing transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2021; 99:160-168. [PMID: 34184817 DOI: 10.1002/ccd.29847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES This study sought to examine the association of hospital procedural volume with the incidence and outcomes of surgical bailout (SB) in patients who undergo transcatheter aortic valve replacement (TAVR). BACKGROUND SB is required for serious complications during or after TAVR. It remains unclear whether hospital experiences affect the incidence and outcomes of SB. METHODS We retrospectively identified patients who underwent endovascular TAVR using the Nationwide Readmissions Database 2012-2017. We examined the association of annual hospital procedural volume (annual number of endovascular TAVR cases in each hospital in each year) with the incidence and in-hospital mortality of SB using multivariable logistic regressions and restricted cubic splines. RESULTS Among 82,764 eligible patients, the incidence of SB was 0.95% (n = 789) and decreased from 2012 to 2017 (from 2.66% to 0.49%; Ptrend < 0.001), while in-hospital mortality of SB remained high over years (from 26.0% to 23.5%; Ptrend = 0.773). Very-high-volume hospitals (≥200 cases/year), as compared with low-volume hospitals (≤49 cases/year), showed significantly a lower incidence of SB (0.49% vs. 1.81%; adjusted OR = 0.28, 95% CI = 0.21-0.38), but similar in-hospital mortality of SB (26.2% vs. 25.6%; adjusted OR = 0.88, 95% CI = 0.47-1.66). There was a significant nonlinear, inverse association of hospital volume with the incidence of SB, but not with the in-hospital mortality of SB. CONCLUSIONS Hospitals with higher TAVR volumes have a lower risk of SB, but the in-hospital mortality after SB does not change with hospital TAVR volume. Our findings highlight the importance that physicians should always be aware of the high mortality risk of SB following TAVR regardless of hospital procedural experiences.
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Affiliation(s)
- Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anas M Saad
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keerat Rai Ahuja
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shashank Shekhar
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Omar M Abdelfattah
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Manpreet Kaur
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed M Gad
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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8
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Jauch EC, Schwamm LH, Panagos PD, Barbazzeni J, Dickson R, Dunne R, Foley J, Fraser JF, Lassers G, Martin-Gill C, O'Brien S, Pinchalk M, Prabhakaran S, Richards CT, Taillac P, Tsai AW, Yallapragada A. Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities From the Prehospital Stroke System of Care Consensus Conference: A Consensus Statement From the American Academy of Neurology, American Heart Association/American Stroke Association, American Society of Neuroradiology, National Association of EMS Physicians, National Association of State EMS Officials, Society of NeuroInterventional Surgery, and Society of Vascular and Interventional Neurology: Endorsed by the Neurocritical Care Society. Stroke 2021; 52:e133-e152. [PMID: 33691507 DOI: 10.1161/strokeaha.120.033228] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | - Robert Dunne
- Detroit East Medical Control Authority, MI (R. Dunne).,National Association of EMS Physicians (R. Dunne, C.M.-G.)
| | | | - Justin F Fraser
- University of Kentucky, Lexington (J.F.F.).,American Association of Neurological Surgeons, Society of NeuroInterventional Surgery (J.F.F.)
| | | | | | | | - Mark Pinchalk
- City of Pittsburgh Emergency Medical Services, PA (M.P.)
| | - Shyam Prabhakaran
- University of Chicago, IL (S.P.).,American Academy of Neurology (S.P.)
| | | | - Peter Taillac
- University of Utah, Salt Lake City (P.T.).,National Association of State EMS Officials (P.T.)
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9
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Walsh KA, Plunkett T, O'Brien KK, Teljeur C, Smith SM, Harrington P, Ryan M. The relationship between procedural volume and patient outcomes for percutaneous coronary interventions: a systematic review and meta-analysis. HRB Open Res 2021; 4:10. [PMID: 33842830 PMCID: PMC8008355 DOI: 10.12688/hrbopenres.13203.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 11/20/2022] Open
Abstract
Background: The relationship between procedural volume and outcomes for percutaneous coronary interventions (PCI) is contentious, with previous reviews suggesting an inverse volume-outcome relationship. The aim of this study was to systematically review contemporary evidence to re-examine this relationship. Methods: A systematic review and meta-analysis was undertaken to examine the relationship between PCI procedural volume (both at hospital- and operator-levels) and outcomes in adults. The primary outcome was mortality. The secondary outcomes were complications, healthcare utilisation and process outcomes. Searches were conducted from 1 January 2008 to 28 May 2019. Certainty of the evidence was assessed using ‘Grading of Recommendations, Assessment, Development and Evaluations’ (GRADE). Screening, data extraction, quality appraisal and GRADE assessments were conducted independently by two reviewers. Results: Of 1,154 unique records retrieved, 22 observational studies with 6,432,265 patients were included. No significant association was found between total PCI hospital volume and mortality (odds ratio [OR]: 0.84, 95% confidence interval [CI]: 0.69-1.03,
I
2 = 86%). A temporal trend from significant to non-significant pooled effect estimates was observed. The pooled effect estimate for mortality was found to be significantly in favour of high-volume operators for total PCI procedures (OR: 0.77, 95% CI: 0.63-0.94,
I
2 = 93%), and for high-volume hospitals for primary PCI procedures (OR: 0.77, 95% CI: 0.62-0.94,
I
2 = 78%). Overall, GRADE certainty of evidence was ‘very low’. There were mixed findings for secondary outcomes. Conclusions: A volume-outcome relationship may exist in certain situations, although this relationship appears to be attenuating with time, and there is ‘very low’ certainty of evidence. While volume might be important, it should not be the only standard used to define an acceptable PCI service and a broader evaluation of quality metrics should be considered that encompass patient experience and clinical outcomes. Systematic review registration: PROSPERO,
CRD42019125288
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Affiliation(s)
- Kieran A Walsh
- Health Technology Assessment (HTA) Directorate, Health Information and Quality Authority, Dublin 7, Ireland
| | - Thomas Plunkett
- Health Technology Assessment (HTA) Directorate, Health Information and Quality Authority, Dublin 7, Ireland
| | - Kirsty K O'Brien
- Health Technology Assessment (HTA) Directorate, Health Information and Quality Authority, Dublin 7, Ireland
| | - Conor Teljeur
- Health Technology Assessment (HTA) Directorate, Health Information and Quality Authority, Dublin 7, Ireland
| | - Susan M Smith
- Health Research Board Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Patricia Harrington
- Health Technology Assessment (HTA) Directorate, Health Information and Quality Authority, Dublin 7, Ireland
| | - Máirín Ryan
- Health Technology Assessment (HTA) Directorate, Health Information and Quality Authority, Dublin 7, Ireland.,Department of Pharmacology & Therapeutics, Trinity College Dublin, Dublin 8, Ireland
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10
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Jabir A, Mathew A, Zheng Y, Westerhout C, Viswanathan S, Sebastian P, Kumar P, Bangalore S, Bainey KR, Welsh R. Procedural Volume and Outcomes After Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction in Kerala, India: Report of the Cardiological Society of India-Kerala Primary Percutaneous Coronary Intervention Registry. J Am Heart Assoc 2020; 9:e014968. [PMID: 32476563 PMCID: PMC7429028 DOI: 10.1161/jaha.119.014968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background There are limited data to inform policy mandating primary percutaneous coronary intervention (PPCI) volume benchmarks for catheterization laboratories in low‐ and middle‐income countries. Methods and Results This prospective state‐wide registry included ST‐segment–elevation myocardial infarction patients with symptoms of <12 hours, or with ongoing ischemia at 12 to 24 hours, reperfused with PPCI. From June 2013 to March 2016, we recruited 5560 consecutive patients. We categorized hospitals on the basis of annual PPCI volumes into low, medium, and high volume (<100, 100–199, and ≥200 PPCIs per year, respectively). Kaplan‐Meier curves and Cox regression models were used to examine the association between PPCI volume and 1‐year mortality. Among 42 recruiting hospitals, there were 24 (57.2%) low‐volume, 8 (19%) medium‐volume, and 10 (23.8%) high‐volume hospitals. The median (25th–75th percentile) TIMI (Thrombolysis in Myocardial Infarction) ST‐segment–elevation myocardial infarction risk score was 3 (2–5). Cardiac arrest before admission occurred in 4.2%, 2.1%, and 2.9% of cases at low‐, medium‐, and high‐volume hospitals, respectively (P=0.02). Total ischemic time differed significantly among low‐volume (median [25th–75th percentile], 3.5 [2.4–5.5] hours), medium‐volume (median, 3.8 [25th–75th percentile, 2.58–6.05] hours), and high‐volume hospitals (median, 4.16 [25th–75th percentile 2.8–6.3] hours) (P=0.01). Vascular access was radial in 61.5%, 71.3%, and 63.2% of cases at low‐, medium‐, and high‐volume hospitals, respectively (P=0.01). The observed 1‐year mortality rate was 6.5%, 3.4%, and 8.6% at low‐, medium‐ and high‐volume hospitals, respectively (P<0.01), and the difference did not attenuate after multivariate adjustment (low versus medium: hazard ratio [95% CI], 1.80 [1.12–2.90]; high versus medium: hazard ratio [95% CI], 2.53 [1.78–3.58]) (P<0.01). Conclusions Low‐ and middle‐income countries, like India, may have a nonlinear relationship between institutional PPCI volume and outcomes, partly driven by procedural variations and inequalities in access to care.
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Affiliation(s)
| | - Anoop Mathew
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada.,Division of Cardiology Mazankowski Alberta Heart Institute University of Alberta Edmonton Alberta Canada
| | - Yinggan Zheng
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada
| | - Cynthia Westerhout
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada
| | - Sunitha Viswanathan
- Division of Cardiology Government Medical College Hospital Thiruvanathapuram Kerala India
| | - Placid Sebastian
- Division of Cardiology Pariyaram Medical College Hospital Kannur Kerala India
| | - Prasanna Kumar
- Jubilee Medical College Hospital and Research Centre Thrissur Kerala India
| | | | - Kevin R Bainey
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada.,Division of Cardiology Mazankowski Alberta Heart Institute University of Alberta Edmonton Alberta Canada
| | - Robert Welsh
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada.,Division of Cardiology Mazankowski Alberta Heart Institute University of Alberta Edmonton Alberta Canada
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11
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Liao HH, Wang PC, Yeh EH, Lin CJ, Chao TH. Impact of disease-specific care certification on clinical outcome and healthcare performance of myocardial infarction in Taiwan. J Chin Med Assoc 2020; 83:156-163. [PMID: 31834024 DOI: 10.1097/jcma.0000000000000237] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The relationship between certification for specific disease care and clinical outcome was not well known. Previous studies regarding the effect of certification for acute stroke centers were limited by their cross-sectional design. This study aimed to investigate the effect of disease-specific care (DSC) certification on healthcare performance and clinical outcome of acute myocardial infarction (AMI). METHODS This retrospective, longitudinal, controlled study was performed by analyzing the nationwide Taiwan Clinical Performance Indicators dataset from 2011 to 2018. Hospitals undergoing DSC certification for coronary care and reporting AMI indicators 1 year before, during, and 1 year after certification were included in group C, whereas hospitals not seeking DSC certification but reporting AMI indicators during the same period were included in group U. The primary endpoint was in-hospital mortality of AMI. RESULTS In total, 20 hospitals (9 in group C and 11 in group U) and up to 16 173 AMI cases were included for analysis. In-hospital mortality was similar between both groups at baseline. However, the in-hospital mortality was significantly improved during and after certification periods in comparison with that at baseline in group C (6.8% vs 8.4%, p = 0.04; 6.7% vs 8.4%, p = 0.02), whereas there was no significant change in group U, resulting in a statistically significant difference between both groups during and after certification periods (odds ratio = 0.74 [95% CI = 0.60-0.91] and 0.78 [95% CI = 0.64-0.96]). Compared with group U, the improvement in healthcare performance indicators, such as door-to-electrocardiography time <10 minutes, blood testing for low-density lipoprotein cholesterol level, prescribing a beta-blockade or a P2Y12 receptor inhibitor during hospitalization, prescribing a statin on discharge, and consultation for cardiac rehabilitation, was significant in group C. CONCLUSION The current study demonstrated the beneficial effect of DSC certification on clinical outcome of AMI probably mediated through quality improvement during the healthcare process.
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Affiliation(s)
- Hsun-Hsiang Liao
- Joint Commission of Taiwan, Chief Executive Officer Office, New Taipei City, Taiwan, ROC
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan, ROC
| | - Pa-Chun Wang
- Joint Commission of Taiwan, Chief Executive Officer Office, New Taipei City, Taiwan, ROC
- Department of Otolaryngology, Cathay General Hospital, Taipei, Taiwan, ROC
- School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan, ROC
| | - En-Hui Yeh
- Division of Quality Improvement, Joint Commission of Taiwan, New Taipei City, Taiwan, ROC
| | - Chii-Jeng Lin
- Department of Orthopedics, College of Medicine and Hospital, National Cheng Kung University, Tainan, Taiwan, ROC
- President Office, Joint Commission of Taiwan, New Taipei City, Taiwan, ROC
| | - Ting-Hsing Chao
- Department of Internal Medicine, College of Medicine and Hospital, National Cheng Kung University, Tainan, Taiwan, ROC
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12
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Vaughan L, Edwards N. The problems of smaller, rural and remote hospitals: Separating facts from fiction. Future Healthc J 2020; 7:38-45. [PMID: 32104764 PMCID: PMC7032574 DOI: 10.7861/fhj.2019-0066] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Smaller hospitals internationally are under threat. The narratives around the closure of smaller hospitals, regardless of size and location, are all constructed around three common problems - cost, quality and workforce. The literature is reviewed, demonstrating that there is little hard evidence to support the contention that hospital merger/closure solves these problems. The disbenefits of mergers and closures, including loss of resources, increased pressure on neighbouring organisations, shifting risk from the healthcare system to patients and their families, and the threat hospital closure represents to communities, are explored. Alternative structures, policies and funding mechanisms, based on the evidence, are urgently needed to support smaller hospitals in the UK and elsewhere.
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13
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Kim BK, Nah DY, Choi KU, Bae JH, Rhee MY, Jang JS, Moon KW, Lee JH, Kim HY, Kang SH, Song WH, Lee SU, Shim BJ, Chung H, Hyon MS. Impact of Hospital Volume of Percutaneous Coronary Intervention (PCI) on In-Hospital Outcomes in Patients with Acute Myocardial Infarction: Based on the 2014 Cohort of the Korean Percutaneous Coronary Intervention (K-PCI) Registry. Korean Circ J 2020; 50:1026-1036. [PMID: 33118336 PMCID: PMC7596209 DOI: 10.4070/kcj.2020.0172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/21/2020] [Accepted: 07/22/2020] [Indexed: 12/18/2022] Open
Abstract
Background and Objectives The relationship between the hospital percutaneous coronary intervention (PCI) volumes and the in-hospital clinical outcomes of patients with acute myocardial infarction (AMI) remains the subject of debate. This study aimed to determine whether the in-hospital clinical outcomes of patients with AMI in Korea are significantly associated with hospital PCI volumes. Methods We selected and analyzed 17,121 cases of AMI, that is, 8,839 cases of non-ST-segment elevation myocardial infarction and 8,282 cases of ST-segment elevation myocardial infarction, enrolled in the 2014 Korean percutaneous coronary intervention (K-PCI) registry. Patients were divided into 2 groups according to hospital annual PCI volume, that is, to a high-volume group (≥400/year) or a low-volume group (<400/year). Major adverse cardiovascular and cerebrovascular events (MACCEs) were defined as composites of death, cardiac death, non-fatal myocardial infarction (MI), stent thrombosis, stroke, and need for urgent PCI during index admission after PCI. Results Rates of MACCE and non-fatal MI were higher in the low-volume group than in the high-volume group (MACCE: 10.9% vs. 8.6%, p=0.001; non-fatal MI: 4.8% vs. 2.6%, p=0.001, respectively). Multivariate regression analysis showed PCI volume did not independently predict MACCE. Conclusions Hospital PCI volume was not found to be an independent predictor of in-hospital clinical outcomes in patients with AMI included in the 2014 K-PCI registry.
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Affiliation(s)
- Byong Kyu Kim
- Division of Cardiology, Department of Internal Medicine, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Korea
| | - Deuk Young Nah
- Division of Cardiology, Department of Internal Medicine, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Korea.
| | - Kang Un Choi
- Division of Cardiology, Department of Internal Medicine, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Korea
| | - Jun Ho Bae
- Division of Cardiology, Department of Internal Medicine, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Korea
| | - Moo Yong Rhee
- Department of Internal Medicine, Cardiovascular Center, Dongguk University Illsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jae Sik Jang
- Division of Cardiology, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Keon Woong Moon
- Division of Cardiology, Department of Internal Medicine, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Jun Hee Lee
- Division of Cardiology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hee Yeol Kim
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Korea
| | - Seung Ho Kang
- Division of Cardiology, Department of Internal Medicine, Cheju Halla General Hospital, Jeju, Korea
| | - Woo Hyuk Song
- Department of Cardiology, Korea University Ansan Hospital, Ansan, Korea
| | - Seung Uk Lee
- Division of Cardiology, Department of Internal Medicine, Kwangju Christian Hospital, Gwangju, Korea
| | - Byung Ju Shim
- Department of Internal Medicine, Pohang St. Mary's Hospital, Pohang, Korea
| | - Hangjae Chung
- Division of Cardiology, Department of Internal Medicine, Pohang Semyeong Christianity Hospital, Pohang, Korea
| | - Min Su Hyon
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University School of Medicine, Seoul, Korea
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14
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Fanaroff AC, Zakroysky P, Wojdyla D, Kaltenbach LA, Sherwood MW, Roe MT, Wang TY, Peterson ED, Gurm HS, Cohen MG, Messenger JC, Rao SV. Relationship Between Operator Volume and Long-Term Outcomes After Percutaneous Coronary Intervention. Circulation 2019; 139:458-472. [PMID: 30586696 DOI: 10.1161/circulationaha.117.033325] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Although many studies show an inverse association between operator procedural volume and short-term adverse outcomes after percutaneous coronary intervention (PCI), the association between procedural volume and longer-term outcomes is unknown. METHODS Using the National Cardiovascular Data Registry CathPCI registry data linked with Medicare claims data, we examined the association between operator PCI volume and long-term outcomes among patients ≥65 years of age. Operators were stratified by average annual PCI volume (counting PCIs performed in patients of all ages): low- (<50 PCIs), intermediate- (50-100), and high- (>100) volume operators. One-year unadjusted rates of death and major adverse coronary events (MACEs; defined as death, readmission for myocardial infarction, or unplanned coronary revascularization) were calculated with Kaplan-Meier methods. The proportional hazards assumption was not met, and risk-adjusted associations between operator volume and outcomes were calculated separately from the time of PCI to hospital discharge and from hospital discharge to 1-year follow-up. RESULTS Between July 1, 2009, and December 31, 2014, 723 644 PCI procedures were performed by 8936 operators: 2553 high-, 2878 intermediate-, and 3505 low-volume operators. Compared with high- and intermediate-volume operators, low-volume operators more often performed emergency PCI, and their patients had fewer cardiovascular comorbidities. Over 1-year follow-up, 15.9% of patients treated by low-volume operators had a MACE compared with 16.9% of patients treated by high-volume operators ( P=0.004). After multivariable adjustment, intermediate- and high-volume operators had a significantly lower rate of in-hospital death than low-volume operators (odds ratio, 0.91; 95% CI, 0.86-0.96 for intermediate versus low; odds ratio, 0.79; 95% CI, 0.75-0.83 for high versus low). There were no significant differences in rates of MACEs, death, myocardial infarction, or unplanned revascularization between operator cohorts from hospital discharge to 1-year follow-up (adjusted hazard ratio for MACEs, 0.99; 95% CI, 0.96-1.01 for intermediate versus low; hazard ratio, 1.01; 95% CI, 0.99-1.04 for high versus low). CONCLUSIONS Unadjusted 1-year outcomes after PCI were worse for older adults treated by operators with higher annual volume; however, patients treated by these operators had more cardiovascular comorbidities. After risk adjustment, higher operator volume was associated with lower in-hospital mortality and no difference in postdischarge MACEs.
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Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology (A.C.F., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Pearl Zakroysky
- Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Daniel Wojdyla
- Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Matthew W Sherwood
- Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC.,Division of Cardiology, Inova Heart and Vascular Institute, Falls Church, VA (M.W.S.)
| | - Matthew T Roe
- Division of Cardiology (A.C.F., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Tracy Y Wang
- Division of Cardiology (A.C.F., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Eric D Peterson
- Division of Cardiology (A.C.F., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Hitinder S Gurm
- Division of Cardiology, University of Michigan, Ann Arbor (H.S.G.)
| | | | | | - Sunil V Rao
- Division of Cardiology (A.C.F., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
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15
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Khera R, Pandey A, Koshy T, Ayers C, Nallamothu BK, Das SR, Drazner MH, Jessen ME, Kirtane AJ, Gardner TJ, de Lemos JA, Bhatt DL, Kumbhani DJ. Role of Hospital Volumes in Identifying Low-Performing and High-Performing Aortic and Mitral Valve Surgical Centers in the United States. JAMA Cardiol 2019; 2:1322-1331. [PMID: 29117319 DOI: 10.1001/jamacardio.2017.4003] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Identifying high-performing surgical valve centers with the best surgical outcomes is challenging. Hospital surgical volume is a frequently used surrogate for outcomes. However, its ability to distinguish low-performing and high-performing hospitals remains unknown. Objective To examine the association of hospital procedure volume with hospital performance for aortic and mitral valve (MV) surgical procedures. Design, Setting, and Participants Within an all-payer nationally representative data set of inpatient hospitalizations, this study identified 682 unique hospitals performing surgical aortic valve replacement (SAVR) and MV replacement and repair with or without coronary artery bypass grafting (CABG) between 2007 and 2011. Procedural outcomes were further assessed for a 10-year period (2005-2014) to assess representativeness of study period. Main Outcomes and Measures In-hospital risk-standardized mortality rate (RSMR) calculated using hierarchical models and an empirical bayesian approach with volume-based shrinkage that allowed for reliability adjustment. Results At 682 US hospitals, 70 295 SAVR, 19 913 MV replacement, and 17 037 MV repair procedures were performed between 2007 and 2011, with a median annual volume of 43 (interquartile range [IQR], 23-76) SAVR, 13 (IQR, 6-22) MV replacement, and 9 (IQR, 4-19) MV repair procedures. Of 225 SAVR hospitals in the highest-volume tertile, 34.7% and 36.0% were in the highest-RSMR tertile for SAVR + CABG and isolated SAVR procedures, respectively, while 21.5% and 17.5% of the 228 SAVR hospitals in the lowest-volume tertile were in the lowest respective RSMR tertile. Similarly, 36.8% and 43.5% of hospitals in the highest tertile of volume for MV replacement and repair, respectively, were in the corresponding highest-RSMR tertile, and 17.4% and 11.2% of the low-volume hospitals were in the lowest-RSMR tertile for MV replacement and repair, respectively. There was limited correlation between outcomes for SAVR and MV procedures at an institution. If solely volume-based tertiles were used to categorize hospitals for quality, 44.7% of all valve hospitals would be misclassified (as either low performing or high performing) when assessing performance based on tertiles of RSMR. Conclusions and Relevance Hospital procedure volume alone frequently misclassifies hospital performance with regard to risk-standardized outcomes after aortic and MV surgical procedures. Valve surgery quality improvement endeavors should focus on a more comprehensive assessment that includes risk-adjusted outcomes rather than hospital volume alone.
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Affiliation(s)
- Rohan Khera
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Thomas Koshy
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Colby Ayers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Sandeep R Das
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Michael E Jessen
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Ajay J Kirtane
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York.,Associate Editor
| | - Timothy J Gardner
- Center for Heart & Vascular Health, Christiana Care Health System, Wilmington, Delaware
| | - James A de Lemos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Dharam J Kumbhani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
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16
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Kumbhani DJ, Nallamothu BK. PCI Volume Benchmarks: Still Adequate for Quality Assessment in 2017? J Am Coll Cardiol 2019; 69:2925-2928. [PMID: 28619192 DOI: 10.1016/j.jacc.2017.04.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Dharam J Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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17
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Improving Quality and Outcomes in TAVR: Turning Up the Volume? J Am Coll Cardiol 2019; 73:441-443. [PMID: 30704576 DOI: 10.1016/j.jacc.2018.09.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/11/2018] [Indexed: 11/21/2022]
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18
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Kumbhani DJ, Bittl JA. Much Ado About Nothing? The Relationship of Institutional Percutaneous Coronary Intervention Volume to Mortality. Circ Cardiovasc Qual Outcomes 2018; 10:CIRCOUTCOMES.117.003610. [PMID: 28320708 DOI: 10.1161/circoutcomes.117.003610] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Dharam J Kumbhani
- From the Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (D.J.K.); and Interventional Cardiology Group, Munroe Regional Medical Center, Ocala, FL (J.A.B.).
| | - John A Bittl
- From the Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (D.J.K.); and Interventional Cardiology Group, Munroe Regional Medical Center, Ocala, FL (J.A.B.)
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19
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Jahic E. Experience and Outcomes of Primary Percutaneous Coronary Intervention for Patients with ST-Segment Elevation Myocardial Infarction of Tertiary Care Center in Bosnia and Herzegovina. Med Arch 2018; 71:183-187. [PMID: 28974830 PMCID: PMC5585807 DOI: 10.5455/medarh.2017.71.183-187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: Primary percutaneous coronary intervention (PCI) is an emergent percutaneous catheter intervention in the setting of ST-segment elevations myocardial infarction (STEMI), without previous fibrinolytic treatment. Aim: To evaluate the feasibility and outcomes of primary percutaneous coronary interventions for STEMI in regional tertiary care cardiac centre in Bosnia and Herzegovina. Methods: Between January 2014 and December 2016, consecutive 549 STEMI patients who underwent primary PCI were prospectively enrolled in a primary PCI registry. The most of coronary angiography procedures were performed using the radial artery route. Patient demographics, risk factors, procedural characteristics, time variables and in-hospital events were assessed. Results: On admission, 297 (64.7%) of the patients were current smokers, 234 (42.6%) were hypertensive, 172 (31.3%) were diabetics, and 68 (12.3%) had cardiogenic shock. The mean duration of time from symptom onset to hospital arrival 193±118.2 minutes, and the mean door-to-balloon time was 37±11.3 minutes and median total ischemic time was 265(60-897) minutes. Infarct-related artery (IRA) was the left anterior descending artery in 47.1%, multivessel disease was present in 49.7%. Primary PCI involved balloon dilatation (2.7%) and stent implantation (97.3%). The incidence of postprocedural angiographic no-reflow was 6.7%. All-cause mortality occurred in 17 patients (3.1%). Conclusion: This study has shown feasibility and efficiency in performing of primary PCI with good outcomes in the first regional interventional center in Bosnia and Herzegovina. Experiences and results of our hospital can be very useful in creating primary PCI networks in our countries and developing countries as well.
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Affiliation(s)
- Elmir Jahic
- Department of Interventional Cardiology, Clinic for Cardiovascular Diseases, University Clinical Centre Tuzla, Bosnia and Herzegovina
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20
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The Impact of Formal Training and Certification on the Relationship Between Volume and Outcomes in Percutaneous Coronary Interventions. Crit Pathw Cardiol 2018; 17:155-160. [PMID: 30044257 DOI: 10.1097/hpc.0000000000000153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Little data are available on the impact of formal training and certification on the relationship between volumes and outcome in percutaneous coronary interventions (PCIs).The objective of this report is to study the relationship between PCI volume and outcome for a formally trained interventional cardiologist who is certified by the American Board on Internal Medicine - Interventional Cardiology subspecialty board. METHODS The operator witnessed 3 different PCI volumes/yr over a 15-year practice period (2000-2014): <50 PCI/yr (years 2000-2006; n = 179), 50-100 PCI/yr (years 2007-2010; n = 256), and >100 PCI/yr (years 2011-2014; n = 427). Angiographic and procedural success rates were compared between the 3 volume groups, as well as in-hospital cardiovascular events (death, recurrent myocardial infarction, repeat PCI, stroke, or coronary artery bypass surgery). RESULTS The in-hospital mortality rate throughout the study period was 0.8% and was not statistically significant among the 3 volume groups. There was also no significant difference among the 3 groups with respect to recurrent myocardial infarction or repeat PCI. There was a slightly higher rate of same-stay elective coronary artery bypass grafting in the early low-volume period compared with the other 2 groups (2.2% vs. 0.8% vs. 0.2%; P = 0.04). The overall angiographic and procedural success rates were 97.3% and 96.5%, and they were not significantly different among the 3 groups. CONCLUSIONS Our study shows that the angiographic and procedural success rates of PCI, as well as the in-hospital mortality, do not seem to be dependent on the annual volume for formally trained and certified interventional cardiologists.
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Kumbhani DJ, Fonarow GC, Heidenreich PA, Schulte PJ, Lu D, Hernandez A, Yancy C, Bhatt DL. Association Between Hospital Volume, Processes of Care, and Outcomes in Patients Admitted With Heart Failure. Circulation 2018; 137:1661-1670. [DOI: 10.1161/circulationaha.117.028077] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 11/22/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Dharam J. Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.J.K.)
| | - Gregg C. Fonarow
- UCLA Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, CA (G.C.F.)
| | | | - Phillip J. Schulte
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (P.J.S., D.L., A.H.)
| | - Di Lu
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (P.J.S., D.L., A.H.)
| | - Adrian Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (P.J.S., D.L., A.H.)
| | - Clyde Yancy
- Department of Cardiology, Northwestern Fienberg School of Medicine, Chicago, IL (C.Y.)
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
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Gupta T, Patel K, Kolte D, Khera S, Villablanca PA, Aronow WS, Frishman WH, Cooper HA, Bortnick AE, Fonarow GC, Panza JA, Weisz G, Menegus MA, Garcia MJ, Bhatt DL. Relationship of Hospital Teaching Status with In-Hospital Outcomes for ST-Segment Elevation Myocardial Infarction. Am J Med 2018; 131:260-268.e1. [PMID: 29037939 DOI: 10.1016/j.amjmed.2017.09.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 09/10/2017] [Accepted: 09/11/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prior analyses have largely shown a survival advantage with admission to a teaching hospital for acute myocardial infarction. However, most prior studies report data on patients hospitalized over a decade ago. It is important to re-examine the association of hospital teaching status with outcomes of acute myocardial infarction in the current era. METHODS We queried the 2010 to 2014 National Inpatient Sample databases to identify all patients aged ≥18 years hospitalized with the principal diagnosis of ST-segment elevation myocardial infarction (STEMI). Multivariable logistic regression models were constructed to compare rates of reperfusion and in-hospital outcomes between patients admitted to teaching vs nonteaching hospitals. RESULTS Of 546,252 patients with STEMI, 273,990 (50.1%) were admitted to teaching hospitals. Compared with patients admitted to nonteaching hospitals, those at teaching hospitals were more likely to receive reperfusion therapy during the hospitalization (86.7% vs 81.5%; adjusted odds ratio [OR] 1.41; 95% confidence interval [CI], 1.39-1.44; P < .001) and had lower risk-adjusted in-hospital mortality (4.9% vs 6.9%; adjusted OR 0.84; 95% CI, 0.82-0.86; P < .001). After further adjustment for differences in use of in-hospital reperfusion therapy, the association of teaching hospital status with lower risk-adjusted in-hospital mortality was significantly attenuated but remained statistically significant (adjusted OR 0.97; 95% CI, 0.94-0.99; P = .02). CONCLUSIONS Patients admitted to teaching hospitals are more likely to receive reperfusion and have lower risk-adjusted in-hospital mortality after STEMI compared with those admitted to nonteaching hospitals. Our results suggest that hospital performance for STEMI continues to be better at teaching hospitals in the contemporary era.
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Affiliation(s)
- Tanush Gupta
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Kavisha Patel
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Dhaval Kolte
- Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI
| | - Sahil Khera
- Division of Cardiology, Massachusetts General Hospital, Boston
| | - Pedro A Villablanca
- Division of Cardiology, New York University Langone Medical Center, New York
| | - Wilbert S Aronow
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla
| | - William H Frishman
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla
| | - Howard A Cooper
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla
| | - Anna E Bortnick
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles
| | - Julio A Panza
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla
| | - Giora Weisz
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Mark A Menegus
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Mario J Garcia
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA.
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24
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O'Neill D, Nicholas O, Gale CP, Ludman P, de Belder MA, Timmis A, Fox KAA, Simpson IA, Redwood S, Ray SG. Total Center Percutaneous Coronary Intervention Volume and 30-Day Mortality: A Contemporary National Cohort Study of 427 467 Elective, Urgent, and Emergency Cases. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003186. [PMID: 28320707 DOI: 10.1161/circoutcomes.116.003186] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 02/20/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relationship between procedural volume and prognosis after percutaneous coronary intervention (PCI) remains uncertain, with some studies finding in favor of an inverse association and some against. This UK study provides a contemporary reassessment in one of the few countries in the world with a nationally representative PCI registry. METHODS AND RESULTS A nationwide cohort study was performed using the national British Cardiovascular Intervention Society registry. All adult patients undergoing PCI in 93 English and Welsh NHS hospitals between 2007 and 2013 were analyzed using hierarchical modeling with adjustment for patient risk. Of 427 467 procedures (22.0% primary PCI) in 93 hospitals, 30-day mortality was 1.9% (4.8% primary PCI). 87.1% of centers undertook between 200 and 2000 procedures annually. Case mix varied with center volume. In centers with 200 to 399 PCI cases per year, a smaller proportion were PCI for ST-segment-elevation myocardial infarction (8.4%) than in centers with 1500 to 1999 PCI cases per year (24.2%), but proportionally more were for ST-segment-elevation myocardial infarction with cardiogenic shock (8.4% versus 4.3%). For the overall PCI cohort, after risk adjustment, there was no significant evidence of worse, or better, outcomes in lower volume centers from our own study, or in combination with results from other studies. For primary PCI, there was also no evidence for increased or decreased mortality in lower volume centers. CONCLUSIONS After adjustment for differences in case mix and clinical presentation, this study supports the conclusion of no trend for increased mortality in lower volume centers for PCI in the UK healthcare system. CLINICAL TRIAL REGISTRATION https://www.clinicaltrials.gov. Unique identifier: NCT02184949.
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Affiliation(s)
- Darragh O'Neill
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.).
| | - Owen Nicholas
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Chris P Gale
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Peter Ludman
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Mark A de Belder
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Adam Timmis
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Keith A A Fox
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Iain A Simpson
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Simon Redwood
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Simon G Ray
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
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25
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Acharya T, Salisbury AC, Spertus JA, Kennedy KF, Bhullar A, Reddy HKK, Joshi BK, Ambrose JA. In-Hospital Outcomes of Percutaneous Coronary Intervention in America’s Safety Net. JACC Cardiovasc Interv 2017; 10:1475-1485. [DOI: 10.1016/j.jcin.2017.05.042] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/15/2017] [Accepted: 05/18/2017] [Indexed: 10/19/2022]
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26
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Exploring the Relationship Between Volume and Outcomes in Hospital Cardiovascular Care. Qual Manag Health Care 2017; 26:160-164. [DOI: 10.1097/qmh.0000000000000142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ikemura N, Sawano M, Shiraishi Y, Ueda I, Miyata H, Numasawa Y, Noma S, Suzuki M, Momiyama Y, Inohara T, Hayashida K, Yuasa S, Maekawa Y, Fukuda K, Kohsaka S. Barriers Associated With Door-to-Balloon Delay in Contemporary Japanese Practice. Circ J 2017; 81:815-822. [PMID: 28228609 DOI: 10.1253/circj.cj-16-0905] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Door-to-balloon (DTB) time ≤90 min is an important quality indicator in the management of ST-elevation myocardial infarction (STEMI), but a considerable number of patients still do not meet this goal, particularly in countries outside the USA and Europe.Methods and Results:We analyzed 2,428 STEMI patients who underwent primary PCI ≤12 h of symptom onset who were registered in an ongoing prospective multicenter database (JCD-KiCS registry), between 2008 and 2013. We analyzed both the time trend in DTB time within this cohort in the registry, and independent predictors of delayed DTB time >90 min. Median DTB time was 90 min (IQR, 68-115 min) during the study period and there were no significant changes with year. Predictors for delay in DTB time included peripheral artery disease, prior revascularization, off-hour arrival, age >75 years, heart failure at arrival, and use of IABP or VA-ECMO. Notably, high-volume PCI-capable institutions (PCI ≥200/year) were more adept at achieving shorter DTB time compared with low-volume institutions (PCI <200/year). CONCLUSIONS Half of the present STEMI patients did not achieve DTB time ≤90 min. Targeting the elderly and patients with multiple comorbidities, and PCI performed in off-hours may aid in its improvement.
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Affiliation(s)
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine
| | | | - Ikuko Ueda
- Department of Cardiology, Keio University School of Medicine
| | - Hiroaki Miyata
- Department of Health Policy and Management, Keio University School of Medicine
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital
| | | | - Masahiro Suzuki
- Department of Cardiology, National Hospital Organization, Saitama National Hospital
| | - Yukihiko Momiyama
- Department of Cardiology, National Hospital Organization, Tokyo Medical Center
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine
| | | | - Shinsuke Yuasa
- Department of Cardiology, Keio University School of Medicine
| | | | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
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28
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Abstract
Acute myocardial infarction has traditionally been divided into ST elevation or non-ST elevation myocardial infarction; however, therapies are similar between the two, and the overall management of acute myocardial infarction can be reviewed for simplicity. Acute myocardial infarction remains a leading cause of morbidity and mortality worldwide, despite substantial improvements in prognosis over the past decade. The progress is a result of several major trends, including improvements in risk stratification, more widespread use of an invasive strategy, implementation of care delivery systems prioritising immediate revascularisation through percutaneous coronary intervention (or fibrinolysis), advances in antiplatelet agents and anticoagulants, and greater use of secondary prevention strategies such as statins. This seminar discusses the important topics of the pathophysiology, epidemiological trends, and modern management of acute myocardial infarction, focusing on the recent advances in reperfusion strategies and pharmacological treatment approaches.
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Affiliation(s)
- Grant W Reed
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Jeffrey E Rossi
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Christopher P Cannon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Executive Director Cardiometabolic Trials, Harvard Clinical Research Institute, Boston, MA, USA.
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Abstract
Percutaneous coronary intervention (PCI) is an integral treatment modality for acute coronary syndromes (ACS) as well as chronic stable coronary artery disease (CAD) not responsive to optimal medical therapy. This coupled with studies on the feasibility and safety of performing PCI in centers without on-site surgical backup led to widespread growth of PCI centers. However, this has been accompanied by a recent steep decline in the volume of PCIs at both the operator and hospital level, which raises concerns regarding minimal procedural volumes required to maintain necessary skills and favorable clinical outcomes. The 2011 ACC/AHA/SCAI competency statement required PCI be performed by operators with a minimal procedural volume of >75 PCIs annually at high-volume centers with >400 PCIs per year, a number which was relaxed in the 2013 ACC/AHA/SCAI update to >50 PCIs/operator/year in hospitals with >200 PCIs annually to coincide with reduction in national PCI volume. Recent data suggests that many hospitals do not meet these thresholds. We review data on the importance of volume as a vital quality metric at both an operator and hospital level in determining procedural outcomes following PCI.
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30
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Liu CW, Liao PC, Chen KC, Hsu JC, Li AH, Tu CM, Wu YW. Baseline Hemoglobin Levels Associated with One-Year Mortality in ST-Segment Elevation Myocardial Infarction Patients. ACTA CARDIOLOGICA SINICA 2016; 32:656-666. [PMID: 27899852 DOI: 10.6515/acs20160106a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND The association between hemoglobin (Hb) levels and mortality in patients with ST-segment elevation myocardial infarction (STEMI) remains controversial. The purpose of this study was to examine the mortality among STEMI patients with anemia or erythrocytosis, and further establish the relationship between mortality and the increment of Hb level. METHODS Between 2006 and 2012, 951 consecutive patients with STEMI undergoing primary percutaneous coronary intervention in a medical center in Northern Taiwan were enrolled in our study, including 535 patients with normal Hb level, 148 with anemia (male Hb ≤ 13 g/dl, female ≤ 12) and 268 with erythrocytosis (male Hb ≥ 16, female ≥ 15). RESULTS Patients in the anemia group were the oldest, and had higher morbidity than the normal Hb group, followed by the erythrocytosis group. In regression analyses, neither anemia nor erythrocytosis was associated with 30-day and 1-year mortality. Each 1-g/dl increment of Hb level was not associated with 30-day mortality both in patients with anemia or erythrocytosis. However, it was associated with a decreased risk of 1-year mortality in anemic patients [hazard ratio (HR): 0.756, 95% confidence interval (CI): 0.608-0.938, p = 0.011] and an increased risk of 1-year mortality in those with erythrocytosis (HR: 2.086, 95%CI: 1.106-3.937, p = 0.023). In multivariate analysis, each 1-g/dl increment of Hb level was associated with 1-year mortality both in anemic patients and those with erythrocytosis (HR: 0.788, 95%CI: 0.621-0.999, p = 0.049; HR: 2.302, 95%CI: 1.051-5.04, p = 0.037). CONCLUSIONS Higher hemoglobin levels in STEMI patients with anemia were associated with decreased risks of 1-year mortality, whereas higher hemoglobin levels in those with erythrocytosis were associated with increased risks of one-year mortality.
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Affiliation(s)
- Cheng-Wei Liu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City; ; Department of Internal Medicine, Tri-Service General Hospital, Songshan Branch; ; National Defense Medical Center
| | - Pen-Chih Liao
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City
| | - Kuo-Chin Chen
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City
| | - Jung-Cheng Hsu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City; ; Chihlee Institute of Technology
| | - Ai-Hsien Li
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City
| | - Chung-Ming Tu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City; ; Chihlee Institute of Technology
| | - Yen-Wen Wu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City; ; Departments of Internal Medicine; ; Departments of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei; ; Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City; ; National Yang-Ming University School of Medicine, Taipei, Taiwan
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31
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Liu CW, Liao PC, Chen KC, Chiu YW, Liu YH, Ke SR, Wu YW. Relationship of serum uric acid and Killip class on mortality after acute ST-segment elevation myocardial infarction and primary percutaneous coronary intervention. Int J Cardiol 2016; 226:26-33. [PMID: 27780079 DOI: 10.1016/j.ijcard.2016.10.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 10/06/2016] [Accepted: 10/09/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND There is conflicting information regarding the association between hyperuricemia and survival in STEMI patients. Our study examined the interaction between hyperuricemia and Killip class on mortality of STEMI patients. METHODS We analyzed 951 consecutive STEMI patients between February 2006 and September 2012. Hyperuricemia was defined as SUA of at least 7mg/dL in males and 6mg/dL in females. Killip class I patients were divided into hyperuricemia and normouricemia groups. RESULTS The Killip class I hyperuricemia and normouricemia groups had similar baseline and procedural characteristics, but the hyperuricemia group had significantly greater BMI, serum creatinine, and SUA, and a lower TIMI risk score (2, IQR: 1-4 vs. 3, IQR: 2-4, p=0.019). The hyperuricemia group also had greater 30-day and 1-year mortality rates (2.9% vs. 0.3%, p=0.022; 6.5% vs. 1.1%, p=0.002, respectively). However, hyperuricemia was not associated with mortality of patients in Killip classes II-IV or in the overall study population. Hyperuricemia was associated with increased mortality in subgroups of patients who were at least 65years-old, male, had BMI of 25kg/m2 or less, were in Killip class I, without diabetes, and who did not receive intra-aortic balloon pump support. Hyperuricemia interacted with Killip class I in increasing the risk for 1-year mortality (p for interaction=0.038). CONCLUSIONS Hyperuricemia increased the 1-year mortality of STEMI patients in Killip class I, but not of patients in Killip classes II-IV. An interaction of hyperuricemia and Killip class significantly affects the mortality of STEMI patients.
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Affiliation(s)
- Cheng-Wei Liu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Department of Internal Medicine, Tri-service General Hospital, Songshan Branch, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taiwan
| | - Pen-Chih Liao
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Kuo-Chin Chen
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Yu-Wei Chiu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Department of Computer Science & Engineering, Yuan Ze University, Taiwan
| | - Yuan-Hung Liu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Shin-Rong Ke
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
| | - Yen-Wen Wu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Nuclear Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; National Yang-Ming University School of Medicine, Taipei, Taiwan
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Hira RS, Bhatt DL, Fonarow GC, Heidenreich PA, Ju C, Virani SS, Bozkurt B, Petersen LA, Hernandez AF, Schwamm LH, Eapen ZJ, Albert MA, Liang L, Matsouaka RA, Peterson ED, Jneid H. Temporal Trends in Care and Outcomes of Patients Receiving Fibrinolytic Therapy Compared to Primary Percutaneous Coronary Intervention: Insights From the Get With The Guidelines Coronary Artery Disease (GWTG-CAD) Registry. J Am Heart Assoc 2016; 5:JAHA.116.004113. [PMID: 27792640 PMCID: PMC5121508 DOI: 10.1161/jaha.116.004113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Timely reperfusion after ST‐elevation myocardial infarction (STEMI) improves survival. Guidelines recommend primary percutaneous coronary intervention (PPCI) within 90 minutes of arrival at a PCI‐capable hospital. The alternative is fibrinolysis within 30 minutes for those in those for whom timely transfer to a PCI‐capable hospital is not feasible. Methods and Results We identified STEMI patients receiving reperfusion therapy at 229 hospitals participating in the Get With the Guidelines—Coronary Artery Disease (GWTG‐CAD) database (January 1, 2003 through December 31, 2008). Temporal trends in the use of fibrinolysis and PPCI, its timeliness, and in‐hospital mortality outcomes were assessed. We also assessed predictors of fibrinolysis versus PPCI and compliance with performance measures. Defect‐free care was defined as 100% compliance with all performance measures. We identified 29 190 STEMI patients, of whom 2441 (8.4%) received fibrinolysis; 38.2% of these patients achieved door‐to‐needle times ≤30 minutes. Median door‐to‐needle times increased from 36 to 60 minutes (P=0.005) over the study period. Among PPCI patients, median door‐to‐balloon times decreased from 94 to 64 minutes (P<0.0001) over the same period. In‐hospital mortality was higher with fibrinolysis than with PPCI (4.6% vs 3.3%, P=0.001) and did not change significantly over time. Patients receiving fibrinolysis were less likely to receive defect‐free care compared with their PPCI counterparts. Conclusions Use of fibrinolysis for STEMI has decreased over time with concomitant worsening of door‐to‐needle times. Over the same time period, use of PPCI increased with improvement in door‐to‐balloon times. In‐hospital mortality was higher with fibrinolysis than with PPCI. As reperfusion for STEMI continues to shift from fibrinolysis to PPCI, it will be critical to ensure that door‐to‐needle times and outcomes do not worsen.
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Affiliation(s)
- Ravi S Hira
- Division of Cardiology, University of Washington, Seattle, WA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | | | - Paul A Heidenreich
- Veterans Administration Palo Alto Healthcare System, Palo Alto, CA Stanford University School of Medicine, Stanford, CA
| | - Christine Ju
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Salim S Virani
- Michael E. DeBakey VA Medical Center, Houston, TX Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, TX
| | - Biykem Bozkurt
- Michael E. DeBakey VA Medical Center, Houston, TX Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Laura A Petersen
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, TX
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Lee H Schwamm
- Department of Neurology, TeleStroke and Acute Stroke Services, Boston, MA Institute for Heart, Vascular, and Stroke Care, Massachusetts General Hospital, Boston, MA Department of Neurology, Harvard Medical School, Boston, MA
| | - Zubin J Eapen
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Michelle A Albert
- Division of Cardiology, University of California at San Francisco, San Francisco, CA
| | - Li Liang
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Hani Jneid
- Michael E. DeBakey VA Medical Center, Houston, TX Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
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Haas C, Fournier S, Iglesias JF, Trana C, Roguelov C, Locca D, Lauriers N, Muller O, Eeckhout E. Assessment of quality performance measures for primary percutaneous coronary intervention: A report from a tertiary referral centre in Switzerland. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:435-442. [DOI: 10.1177/2048872615610892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 09/20/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Céline Haas
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Switzerland
| | - Stephane Fournier
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Switzerland
| | | | - Catalina Trana
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Switzerland
| | - Christan Roguelov
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Switzerland
| | - Didier Locca
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Switzerland
| | - Nathalie Lauriers
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Switzerland
| | - Olivier Muller
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Switzerland
| | - Eric Eeckhout
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Switzerland
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Bugami SA, Alrahimi J, Almalki A, Alamger F, Krimly A, Kashkari WA. ST-Segment Elevation Myocardial Infarction: Door to Balloon Time Improvement Project. Cardiol Res 2016; 7:152-156. [PMID: 28197284 PMCID: PMC5295580 DOI: 10.14740/cr476w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2016] [Indexed: 01/27/2023] Open
Abstract
Background The purpose of this quality improvement project was to evaluate prospectively the causes of delay for patients with acute ST-segment elevation myocardial infarction (STEMI) requiring primary percutaneous coronary intervention (PCI) upon arrival at the emergency department (ED) and implement recommendations to reduce delays and analyze the impact of recommendations to reduce the door-to-balloon (D2B) time in a newly established cardiac center (King Faisal Cardiac Center (KFCC)). Primary PCI has developed as an effective treatment strategy for acute STEMI, the survival rate and patient outcome are however dependent on the time to treatment. The international benchmark for all programs dealing with acute coronary syndrome patients suffering from STEMI has been established as 90 minutes or less from the time the patient arrives at the hospital to the opening of the affected vessel in the cardiac catheterization laboratory “door-to-balloon time” or D2B. In KFCC during the year 2014, the STEMI, D2B time of ≤ 90 minutes was achieved in 25%. Methods We conducted a single center prospective data collection for consecutive patients presenting with STEMI within 24 hours of the onset of chest pain between January 2015 and December 2015. The boundaries of the process began when the patient entered the emergency department and ended when the balloon was inflated during the PCI. Certain well-defined metrics were chosen to drive the change and identify the defect. Results A total of 37 patients presented with STEMI. The number of patients who achieved the target D2B time ≤ 90 minutes was 20 (54%). Nine patients (24.4%) had D2B time between 91 and 120 minutes and eight patients (21.6%) beyond 120 minutes. The delays were due to late identifications of patients with chest pain as well as in obtaining ECG, activation and transport to the catheterization laboratory. Conclusion There was a measurable improvement up to 54%. Several factors have contributed to the delays in achieving the goal standard of above 90%; these include late identifications of patients with STEMI, delays in obtaining the ECG, activation of the catheterization laboratory and delay of patients’ transportation.
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Affiliation(s)
- Saad Al Bugami
- King Saud bin Abdulaziz University for Health Sciences; King Faisal Cardiac Center, King Saud bin Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Jamilah Alrahimi
- King Saud bin Abdulaziz University for Health Sciences; King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Abdullah Almalki
- King Saud bin Abdulaziz University for Health Sciences; King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Farqad Alamger
- King Faisal Cardiac Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Ahmed Krimly
- King Saud bin Abdulaziz University for Health Sciences; King Faisal Cardiac Center, King Saud bin Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Wail Al Kashkari
- King Faisal Cardiac Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
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Lin X, Tao H, Cai M, Liao A, Cheng Z, Lin H. A Systematic Review and Meta-Analysis of the Relationship Between Hospital Volume and the Outcomes of Percutaneous Coronary Intervention. Medicine (Baltimore) 2016; 95:e2687. [PMID: 26844508 PMCID: PMC4748925 DOI: 10.1097/md.0000000000002687] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Previous reviews have suggested that hospital volume is inversely related to in-hospital mortality. However, percutaneous coronary intervention (PCI) practices have changed substantially in recent years, and whether this relationship persists remains controversial.A systematic search was performed using PubMed, Embase, and the Cochrane Library to identify studies that describe the effect of hospital volume on the outcomes of PCI. Critical appraisals of the methodological quality and the risk of bias were conducted independently by 2 authors. Fourteen of 96 potentiality relevant articles were included in the analysis. Twelve of the articles described the relationship between hospital volume and mortality and included data regarding odds ratios (ORs); 3 studies described the relationship between hospital volume and long-term survival, and only 1 study included data regarding hazard ratios (HRs). A meta-analysis of postoperative mortality was performed using a random effects model, and the pooled effect estimate was significantly in favor of high volume providers (OR: 0.79; 95% confidence interval [CI], 0.72-0.86; P < 0.001). A systematic review of long-term survival was performed, and a trend toward better long-term survival in high volume hospitals was observed.This meta-analysis only included studies published after 2006 and revealed that postoperative mortality following PCI correlates significantly and inversely with hospital volume. However, the magnitude of the effect of volume on long-term survival is difficult to assess. Additional research is necessary to confirm our findings and to elucidate the mechanism underlying the volume-outcome relationship.
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Affiliation(s)
- Xiaojun Lin
- From the Department of Health Administration, School of Medicine and Health Management (XL, HT, MC, ZC, HL); and Family Planning Research Institute, Center for Reproductive Medicine, Tongji Medical College, Huazhong University of Science and Technology (AL), Wuhan, China
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López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Indicadores de calidad en cardiología. Principales indicadores para medir la calidad de los resultados (indicadores de resultados) y parámetros de calidad relacionados con mejores resultados en la práctica clínica (indicadores de práctica asistencial). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): Declaración de posicionamiento de consenso de SEC/SECTCV. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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37
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López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Indicadores de calidad en cardiología. Principales indicadores para medir la calidad de los resultados (indicadores de resultados) y parámetros de calidad relacionados con mejores resultados en la práctica clínica (indicadores de práctica asistencial). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): Declaración de posicionamiento de consenso de SEC/SECTCV. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2015.07.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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38
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS guidelines on myocardial revascularization. EUROINTERVENTION 2015; 10:1024-94. [PMID: 25187201 DOI: 10.4244/eijy14m09_01] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Stephan Windecker
- Cardiology, Bern University Hospital, Freiburgstrasse 4, CH-3010 Bern, Switzerland
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López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper. ACTA ACUST UNITED AC 2015; 68:976-995.e10. [PMID: 26315766 DOI: 10.1016/j.rec.2015.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/21/2015] [Indexed: 02/06/2023]
Abstract
Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.
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Affiliation(s)
- José López-Sendón
- Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain.
| | - José Ramón González-Juanatey
- Sociedad Española de Cardiología, Madrid, Spain; Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Fausto Pinto
- European Society of Cardiology; Department of Cardiology, University Hospital Santa Maria, Lisbon, Portugal
| | - José Cuenca Castillo
- Sociedad Española de Cirugía Torácica-Cardiovascular; Servicio de Cirugía Cardiaca, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Lina Badimón
- Centro de Investigación Cardiovascular (CSIC-ICCC), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Regina Dalmau
- Unidad de Rehabilitación Cardiaca, Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - Esteban González Torrecilla
- Unidad de Electrofisiología y Arritmias, Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - José Ramón López-Mínguez
- Unidad de Cardiología intervencionista, Servicio de Cardiología, Hospital Infanta Crsitina, Badajoz, Spain
| | - Alicia M Maceira
- Unidad de Imagen Cardiaca, Servicio de Cardiología, ERESA Medical Center, Valencia, Spain
| | - Domingo Pascual-Figal
- Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | | | - Alessandro Sionis
- Unidad de Cuidados Intensivos Cardiológicos, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - José Luis Zamorano
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Shehab A, Al-Habib K, Hersi A, Al-Faleh H, Alsheikh-Ali A, Almahmeed W, Suleiman KJ, Al-Motarreb A, Suwaidy JA, Asaad N, AlSaid S, Hashim M, Amin H. Quality of care in primary percutaneous coronary intervention for acute ST-segment -elevation myocardial infarction: Gulf RACE 2 experience. Ann Saudi Med 2014; 34:482-7. [PMID: 25971820 PMCID: PMC6074571 DOI: 10.5144/0256-4947.2014.482] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Primary percutaneous coronary intervention (pPCI) has been recognized as an effective management strategy for acute ST-segment-elevation myocardial infarction (STEMI). However, there is no first-hand information regarding the quality of pPCI procedures in the Arabian Gulf countries. This study aims to explore the quality of pPCI practice. DESIGN AND SETTINGS The Gulf Race II was designed as a prospective, multinational, multicentre registry of acute coronary events, focusing on the epidemiology, management practices, and outcomes of patients with acute coronary syndrome. The study recruited consecutive patients aged 18 years and above from 65 hospitals in 6 adjacent Middle Eastern countries (Bahrain, Saudi Arabia, Qatar, Oman, United Arab Emirates, and Yemen). PATIENTS AND METHODS We used data from the Gulf Registry of Acute Coronary Events (Gulf RACE 2). We analyzed data on patients who received pPCI to assess the guidelines-supported performance measure of door-to-balloon (D2B).
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Affiliation(s)
- Abdulla Shehab
- A Shehab, MD, Department of Internal Medicine,, College of Medicine and Health Sciences,, UAE University, Al Ain, United Arab Emirates, T: +971506161028,, F: +97137672 995,
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Close, but not close enough. Neth Heart J 2014; 22:510-2. [PMID: 25300740 PMCID: PMC4391181 DOI: 10.1007/s12471-014-0611-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Nippak PMD, Pritchard J, Horodyski R, Ikeda-Douglas CJ, Isaac WW. Evaluation of a regional ST-elevation myocardial infarction primary percutaneous coronary intervention program at the Rouge Valley Health System. BMC Health Serv Res 2014; 14:449. [PMID: 25269747 PMCID: PMC4263118 DOI: 10.1186/1472-6963-14-449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 09/24/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND ST-elevation myocardial infarction (STEMI) remains the second leading cause of death in Canada. Primary percutaneous coronary intervention (PCI) has been recognized as an effective method for treating STEMI. Improved access to primary PCI can be achieved through the implementation of regional PCI centres, which was the impetus for implementing the PCI program in an east Toronto hospital in 2009. As such, the purpose of this study was to measure the efficacy of this program regional expansion. METHODS A retrospective review of 101 patients diagnosed with STEMI from May to Sept 2010 was conducted. The average door-to-balloon time for these STEMI patients was calculated and the door-to-balloon times using different methods of arrival were analyzed. Method of arrival was by one of three ways: paramedic initiated referral; patient walk-ins to PCI centre emergency department; or transfer after walk-in to community hospital emergency department. RESULTS The study found that mean door-to balloon time for PCI was 112.5 minutes. When the door-to-balloon times were compared across the three arrival methods, patients who presented by paramedic-initiated referral had significantly shorter door-to-balloon times, (89.5 minutes) relative to those transferred (120.9 minutes) and those who walked into a PCI centre (126.7 minutes) (p = 0.047). CONCLUSIONS The findings suggest that the partnership between the hospital and its EMS partners should be continued, and paramedic initiated referral should be expanded across Canada and EMS systems where feasible, as this level of coverage does not currently exist nationwide. Investments in regional centres of excellence and the creation of EMS partnerships are needed to enhance access to primary PCI.
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Affiliation(s)
- Pria M D Nippak
- Health Services Management Department, Ryerson University, 350 Victoria St, Toronto, ON M2K 5B3, Canada.
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44
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541-619. [PMID: 25173339 DOI: 10.1093/eurheartj/ehu278] [Citation(s) in RCA: 3275] [Impact Index Per Article: 327.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Kontos MC, Wang Y, Chaudhry SI, Vetrovec GW, Curtis J, Messenger J. Lower Hospital Volume Is Associated With Higher In-Hospital Mortality in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2013; 6:659-67. [DOI: 10.1161/circoutcomes.113.000233] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Current guidelines recommend >36 primary percutaneous coronary interventions (PCIs) per hospital per year. Whether these standards remain valid when routine coronary stenting and newer pharmacological agents are used is unclear.
Methods and Results—
We analyzed patients who underwent primary PCI from July 2006 through June 2009 included in the CathPCI Registry. Hospitals were separated into 3 groups: low (≤36 primary PCIs/y, current guideline recommendation), intermediate (>36–60 primary PCIs/y), and high volume (>60 primary PCIs/y). In-hospital mortality and door-to-balloon time were examined for each group. A total of 87 324 patient visits for 86 044 patients from 738 hospitals were included. There were 278 low- (38%), 236 (32%) intermediate-, and 224 (30%) high-volume hospitals. The majority of patients with primary PCI (54%) were treated at high-volume hospitals, with 15% at low-volume hospitals. Unadjusted mortality was significantly higher in low-volume hospitals compared with high-volume hospitals (5.6% versus 4.8%;
P
<0.001), which was maintained after multivariate adjustment (1.20; 95% confidence interval, 1.08–1.33;
P
=0.001). In contrast, mortality was not significantly different between intermediate-volume and high-volume hospitals (4.8% versus 4.8%; adjusted odds ratio, 1.02; 95% confidence interval, 0.94–1.11;
P
=0.61). Door-to-balloon times were significantly shorter in high-volume hospitals compared with low-volume hospitals (median, 72 minutes; interquartile range, [53–91] versus 77 [57–100] minutes;
P
<0.0001).
Conclusions—
Higher annual hospital volume of primary PCI continues to be associated with lower mortality, with higher mortality in hospitals performing ≤36 primary PCIs/y.
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Affiliation(s)
- Michael C. Kontos
- From the Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA (M.C.K., G.W.V.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.C.); Section of General Internal Medicine, Yale University, New Haven, CT (S.I.C.); and Division of Cardiology, University of Colorado School of Medicine, Aurora, CO (J.M.)
| | - Yongfei Wang
- From the Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA (M.C.K., G.W.V.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.C.); Section of General Internal Medicine, Yale University, New Haven, CT (S.I.C.); and Division of Cardiology, University of Colorado School of Medicine, Aurora, CO (J.M.)
| | - Sarwat I. Chaudhry
- From the Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA (M.C.K., G.W.V.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.C.); Section of General Internal Medicine, Yale University, New Haven, CT (S.I.C.); and Division of Cardiology, University of Colorado School of Medicine, Aurora, CO (J.M.)
| | - George W. Vetrovec
- From the Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA (M.C.K., G.W.V.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.C.); Section of General Internal Medicine, Yale University, New Haven, CT (S.I.C.); and Division of Cardiology, University of Colorado School of Medicine, Aurora, CO (J.M.)
| | - Jeptha Curtis
- From the Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA (M.C.K., G.W.V.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.C.); Section of General Internal Medicine, Yale University, New Haven, CT (S.I.C.); and Division of Cardiology, University of Colorado School of Medicine, Aurora, CO (J.M.)
| | - John Messenger
- From the Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA (M.C.K., G.W.V.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.C.); Section of General Internal Medicine, Yale University, New Haven, CT (S.I.C.); and Division of Cardiology, University of Colorado School of Medicine, Aurora, CO (J.M.)
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Gössl M, Rihal CS, Lennon RJ, Singh M. Assessment of individual operator performance using a risk-adjustment model for percutaneous coronary interventions. Mayo Clin Proc 2013; 88:1250-8. [PMID: 24182704 DOI: 10.1016/j.mayocp.2013.07.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 06/25/2013] [Accepted: 07/01/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate the applicability of the Mayo Clinic Risk Score (MCRS) in the assessment of performance metrics of individual interventional cardiologists at 3 Mayo Clinic sites. PARTICIPANTS AND METHODS We evaluated the risk-adjusted performance of 21 interventional cardiologists who performed 8187 percutaneous coronary intervention procedures at 3 Mayo Clinic sites from January 1, 2007, through December 31, 2010. Observed mortality, major adverse cardiac events (MACEs) (eg, death, Q-wave myocardial infarction, urgent or emergent coronary artery bypass graft, and stroke), and expected risk were estimated using the MCRS. To compare individual performance against the other operators, risk estimates were recalibrated by excluding the individual performer from logistic regression models. RESULTS The log odds ratio for observed vs estimated risk was estimated for each interventional cardiologist, and their individual effects were then plotted on a normal probability plot to identify outliers. Observed in-hospital mortality was not different than expected (1.8% vs 1.6%; P=.24); however, the postprocedural MACE rate was lower than predicted (observed, 2.7%; expected, 3.8%; P<.001). All but one interventional cardiologist had MACE and death rates within the expected variation. Detailed assessment of that operator's risk performance produced excellent outcomes (observed vs expected MACE rate, 1.0% vs 4.4%). CONCLUSION The MCRS can serve as a tool for the assessment of performance metrics for interventional cardiologists, and risk-adjusted outcomes may serve as a better surrogate for institutional quality metrics.
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Affiliation(s)
- Mario Gössl
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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Cavender MA, Rassi AN, Fonarow GC, Cannon CP, Peacock WF, Laskey WK, Hernandez AF, Peterson ED, Cox M, Grau-Sepulveda M, Schwamm LH, Bhatt DL. Relationship of race/ethnicity with door-to-balloon time and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: findings from Get With the Guidelines-Coronary Artery Disease. Clin Cardiol 2013; 36:749-56. [PMID: 24085713 DOI: 10.1002/clc.22213] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 08/26/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Prior studies have described racial/ethnic disparities in door-to-balloon (DTB) time for patients undergoing primary percutaneous coronary intervention (PCI). We sought to compare DTB time between different racial/ethnic groups undergoing primary PCI for ST-elevation myocardial infarction in Get With the Guidelines (GWTG). HYPOTHESIS There may be differences in D2B time associated with race/ethnicity. METHODS We identified 7445 white (n = 6365), African American (n = 568), and Hispanic (n = 512) patients undergoing primary PCI. RESULTS There were no differences in the median DTB time between white (74 minutes; intraquartile range [IQR], 54-99), African American (77 minutes; IQR, 57-100), and Hispanic (75 minutes; IQR, 56-100) (P = 0.13) patients. There were no crude differences in DTB time ≤90 minutes; however, after adjusting for confounders, African American race was associated with lower odds of DTB time ≤90 minutes (odds ratio [OR]: 0.84; 95% confidence interval [CI]: 0.70-0.99; P = 0.04). This association was seen in African American males (OR: 0.66; 95% CI: 0.55-0.80) but not African American females (OR: 1.27; 95% CI: 0.96-1.68). Overall, Hispanic ethnicity was not associated with a difference in DTB time ≤90 minutes (OR: 0.98; 95% CI: 0.77-1.25; P = 0.88); although Hispanic males did have a slightly longer median DTB time compared with whites. During the study, the proportion of patients with DTB times ≤90 minutes increased for all groups, and mortality was similar between groups (white 3.8%, African American 3.0%, Hispanic 4.1%, P = 0.62). CONCLUSIONS In GWTG-Coronary Artery Disease, small differences in DTB times persist among different races/ethnicities. However, the proportion achieving DTB times ≤90 minutes has increased substantially for all patients over time, and there was no association between race/ethnicity and in-hospital mortality.
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Affiliation(s)
- Matthew A Cavender
- Department of Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School Boston, Massachusetts
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Menees DS, Peterson ED, Wang Y, Curtis JP, Messenger JC, Rumsfeld JS, Gurm HS. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med 2013; 369:901-9. [PMID: 24004117 DOI: 10.1056/nejmoa1208200] [Citation(s) in RCA: 511] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Current guidelines for the treatment of ST-segment elevation myocardial infarction recommend a door-to-balloon time of 90 minutes or less for patients undergoing primary percutaneous coronary intervention (PCI). Door-to-balloon time has become a performance measure and is the focus of regional and national quality-improvement initiatives. However, it is not known whether national improvements in door-to-balloon times have been accompanied by a decline in mortality. METHODS We analyzed annual trends in door-to-balloon times and in-hospital mortality using data from 96,738 admissions for patients undergoing primary PCI for ST-segment elevation myocardial infarction from July 2005 through June 2009 at 515 hospitals participating in the CathPCI Registry. In a subgroup analysis using a linked Medicare data set, we assessed 30-day mortality. RESULTS Median door-to-balloon times declined significantly, from 83 minutes in the 12 months from July 2005 through June 2006 to 67 minutes in the 12 months from July 2008 through June 2009 (P<0.001). Similarly, the percentage of patients for whom the door-to-balloon time was 90 minutes or less increased from 59.7% in the first year to 83.1% in the last year (P<0.001). Despite improvements in door-to-balloon times, there was no significant overall change in unadjusted in-hospital mortality (4.8% in 2005-2006 and 4.7% in 2008-2009, P=0.43 for trend) or in risk-adjusted in-hospital mortality (5.0% in 2005-2006 and 4.7% in 2008-2009, P=0.34), nor was a significant difference observed in unadjusted 30-day mortality (P=0.64). CONCLUSIONS Although national door-to-balloon times have improved significantly for patients undergoing primary PCI for ST-segment elevation myocardial infarction, in-hospital mortality has remained virtually unchanged. These data suggest that additional strategies are needed to reduce in-hospital mortality in this population. (Funded by the National Cardiovascular Data Registry of the American College of Cardiology Foundation.).
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Affiliation(s)
- Daniel S Menees
- University of Michigan, Department of Internal Medicine, Division of Cardiovascular Medicine, Ann Arbor, MI 48109, USA.
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Kumbhani DJ, Steg PG, Cannon CP, Eagle KA, Smith SC, Hoffman E, Goto S, Ohman EM, Bhatt DL. Adherence to secondary prevention medications and four-year outcomes in outpatients with atherosclerosis. Am J Med 2013; 126:693-700.e1. [PMID: 23800583 DOI: 10.1016/j.amjmed.2013.01.033] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Revised: 01/21/2013] [Accepted: 01/23/2013] [Indexed: 01/30/2023]
Abstract
BACKGROUND Although nonadherence with evidence-based secondary prevention medications is common in patients with established atherothrombotic disease, long-term outcomes studies are scant. We assessed the prevalence and long-term outcomes of nonadherence to secondary prevention (antiplatelet agents, statins, and antihypertensive agents) medications in stable outpatients with established atherothrombosis (coronary, cerebrovascular, or peripheral artery disease) enrolled in the international REduction of Atherothrombosis for Continued Health registry. METHODS Adherence with these medications in eligible patients at baseline and 1-year follow-up was assessed. The primary outcome was a composite of cardiovascular death, myocardial infarction, or stroke at 4 years. RESULTS A total of 37,154 patients with established atherothrombotic disease were included. Adherence rates with all evidence-based medications at baseline and 1 year were 46.7% and 48.2%, respectively. Nonadherence with any medication at baseline (hazard ratio, 1.18; 95% confidence interval, 1.11-1.25) and at 1 year (hazard ratio, 1.19; 95% confidence interval, 1.11-1.28) were both significantly associated with an increased risk of the primary end point. The risk of all-cause mortality was similarly elevated. Corresponding numbers needed to treat were 31 and 25 patients for the composite end point and total mortality, respectively. This also was true for each disease-specific subgroup. Patients who were fully adherent at both time points had the lowest incidence of adverse outcomes, whereas patients who were nonadherent at both time points had the worst outcomes (P < .01). CONCLUSIONS Our analysis of a large international registry demonstrates that nonadherence with evidence-based secondary prevention therapies in patients with established atherothrombosis is associated with a significant increase in long-term adverse events, including mortality.
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Affiliation(s)
- Dharam J Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Harold JG, Bass TA, Bashore TM, Brindiss RG, Brush JE, Burke JA, Dehmers GJ, Deychak YA, Jneids H, Jolliss JG, Landzberg JS, Levine GN, McClurken JB, Messengers JC, Moussas ID, Muhlestein JB, Pomerantz RM, Sanborn TA, Sivaram CA, Whites CJ, Williamss ES, Halperin JL, Beckman JA, Bolger A, Byrne JG, Lester SJ, Merli GJ, Muhlestein JB, Pina IL, Wang A, Weitz HH. ACCF/AHA/SCAI 2013 Update of the Clinical Competence Statement on Coronary Artery Interventional Procedures. Catheter Cardiovasc Interv 2013; 82:E69-111. [DOI: 10.1002/ccd.24985] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - John G. Harold
- American College of Cardiology Foundation representative
| | - Theodore A. Bass
- Society for Cardiovascular Angiography and Interventions representative
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- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | | | | | | | | | - Joshua A. Beckman
- Former Task Force member during the writing effort; Authors with no symbol by their name were included to provide additional content expertise
| | | | | | | | | | | | - Ileana L. Pina
- Former Task Force member during the writing effort; Authors with no symbol by their name were included to provide additional content expertise
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