In-Hospital Risk-Adjusted Mortality Poorly Reflects PCI Quality

Not Only Caseload but Also Patient Selection Is Predictive of Mortality After Pancreatic Resection

Background

Centralization of pancreatic surgery in high-volume centers is regarded as a key strategy in improving the outcome quality. However, the specific factors, in addition to higher case volumes, that influence inhospital mortality remain unclear.

Methods

In this retrospective observational study, the German nationwide diagnostic-related groups statistics were analyzed for 86,073 patients with pancreatic resections. Hospitals performing at least 50 resections per year were identified as high-volume pancreatic centers (HVPCs). Statistical analyses compared crude and adjusted estimates of inhospital mortality for patients treated in HVPCs and non-HVPCs. A generalized mixed model was used for risk adjustment, considering various factors such as age group, sex, diagnosis, and comorbidities (ClinicalTrail.gov, NCT06390891).

Results

A total of 24.2% (n = 20,798) of all pancreatic resections were performed in 23 HVPCs. The crude inhospital mortality for all patients undergoing resection was 9.0%. Crude inhospital mortality in HVPCs was 5.5% compared with 10.1% in non-HVPCs (P < 0.001). HVPCs performed more complex resections including more concomitant procedures. On the other hand, HVPCs treated younger patients and patients with less complicated comorbidities. Statistical adjustment of comorbidities and patient characteristics resulted in a significant increase of inhospital mortality from 5.5% to 8.7% in HVPCs.

Conclusions

HVPCs have significantly lower inhospital mortality than the other hospitals. Nevertheless, the superior quality of outcome can be attributed not only to the enhanced expertise of the centers but also, at least in part, to a healthier patient population on average. However, the extent to which this patient selection is due to active selection by the practitioners or other causes remains unclear.

Cardiologists' and patients' views about the informed consent process and their understanding of the anticipated treatment benefits of coronary angioplasty: A survey study

BACKGROUND

Percutaneous coronary intervention is a common revascularisation technique. Serious complications are uncommon, but death is one of them. Seeking informed consent in advance of percutaneous coronary intervention is mandatory. Research shows that percutaneous coronary intervention patients have inaccurate perceptions of risks, benefits and alternative treatments.

AIM

To assess cardiologists' and patients' views about the informed consent process and anticipated treatment benefits.

METHODS

Two cross-sectional, anonymous surveys were distributed in England: an electronic version to a sample of cardiologists and a paper-based version to patients recruited from 10 centres.

RESULTS

A sample of 118 cardiologists and 326 patients completed the surveys. Cardiologists and patients shared similar views on the purpose of informed consent; however, over 40% of patients and over a third of cardiologists agreed with statements that patients do not understand, or remember, the information given to them. Patients placed less value than cardiologists on the consent process and over 60% agreed that patients depended on their doctor to make the decision for them. Patients' and cardiologists' views on the benefits of percutaneous coronary intervention were significantly different; notably, 60% of patients mistakenly believed that percutaneous coronary intervention was curative.

CONCLUSIONS

The percutaneous coronary intervention informed consent process requires improvement to ensure that patients are more involved and accurately understand treatment benefits to make an informed decision. Redesign of the patient pathway is recommended to allow protected time for health professionals to engage in discussions using evidence-based approaches such as 'teach back' and decision support which improve patient comprehension.

Coronary Revascularization in High-Risk Stable Patients With Significant Comorbidities: Challenges in Decision-Making

PURPOSE OF REVIEW

There is a growing cohort of complex high-risk patients with stable ischemic heart disease (SIHD) who present for coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI). These patients are older, have complex coronary disease, and a substantial comorbidity burden including frailty. The procedural risks and outcomes of CABG and PCI in these patients are more difficult to assess based on the available literature, which has generally studied a younger population with a lower comorbidity burden.

RECENT FINDINGS

There have been initiatives to recalibrate and expand risk models derived from procedural registries to inform the care of complex higher-risk patients, including patients "turned down" for CABG. There is greater recognition of the need for improved assessment of risk, quality, and benefits of coronary revascularization in higher-risk SIHD patients with a substantial comorbidity burden. Clinicians and patients should be aware that there are significant evidence gaps regarding revascularization in complex high-risk patients. The limitations of procedural-derived risk scores should be understood when presenting treatment options. Future randomized controlled trials and expanded registries are greatly desired and should be achievable. Meanwhile, a multidisciplinary heart team approach should be employed for proper decision-making.