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Rymer JA, Narcisse DI, Chen A, Wojdyla D, Ashley S, Damluji AA, Shah B, Nanna MG, Swaminathan R, Gutierrez JA, Uzendu A, Nelson AJ, Bethel G, Kearney K, Jones WS, Rao SV, Doll JA. Case Volumes and Outcomes Among Early-Career Interventional Cardiologists in the United States. J Am Coll Cardiol 2024; 83:1990-1998. [PMID: 38749617 PMCID: PMC11173360 DOI: 10.1016/j.jacc.2024.03.395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Little is known about the procedural characteristics, case volumes, and mortality rates for early- vs non-early-career interventional cardiologists in the United States. OBJECTIVES This study examined operator-level data for patients who underwent percutaneous coronary intervention (PCI) between April 2018 and June 2022. METHODS Data were collected from the National Cardiovascular Data Registry CathPCI Registry, American Board of Internal Medicine certification database, and National Plan and Provider Enumeration System database. Early-career operators were within 5 years of the end of training. Annual case volume, expected mortality and bleeding risk, and observed/predicted mortality and bleeding outcomes were evaluated. RESULTS A total of 1,451 operators were early career; 1,011 changed their career status during the study; and 6,251 were non-early career. Overall, 514,540 patients were treated by early-career and 2,296,576 patients by non-early-career operators. The median annual case volume per operator was 59 (Q1-Q3: 31-97) for early-career and 57 (Q1-Q3: 28-100) for non-early-career operators. Early-career operators were more likely to treat patients presenting with ST-segment elevation myocardial infarction and urgent indications for PCI (both P < 0.001). The median predicted mortality risk was 2.0% (Q1-Q3: 1.5%-2.7%) for early-career and 1.8% (Q1-Q3: 1.2%-2.4%) for non-early-career operators. The median predicted bleeding risk was 4.9% (Q1-Q3: 4.2%-5.7%) for early-career and 4.4% (Q1-Q3: 3.7%-5.3%) for non-early-career operators. After adjustment, an increased risk of mortality (OR: 1.08; 95% CI: 1.05-1.17; P < 0.0001) and bleeding (OR: 1.08; 95% CI: 1.05-1.12; P < 0.0001) were associated with early-career status. CONCLUSIONS Early-career operators are caring for patients with more acute presentations and higher predicted risk of mortality and bleeding compared with more experienced colleagues, with modestly worse outcomes. These data should inform institutional practices to support the development of early-career proceduralists.
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Affiliation(s)
- Jennifer A Rymer
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Dennis I Narcisse
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Angel Chen
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah Ashley
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Binita Shah
- Department of Medicine (Cardiology), VA NY Harbor Health Care System, New York, New York, USA; Department of Medicine (Cardiology), NYU School of Medicine, New York, New York, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Rajesh Swaminathan
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - J Antonio Gutierrez
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anezi Uzendu
- Division of Cardiology, University of Texas Southwestern, Dallas, Texas, USA
| | - Adam J Nelson
- University of Adelaide, Adelaide, South Australia, Australia
| | - Garrett Bethel
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Katherine Kearney
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - W Schuyler Jones
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sunil V Rao
- Department of Medicine (Cardiology), NYU School of Medicine, New York, New York, USA
| | - Jacob A Doll
- VA Puget Sound Health Care System, Seattle, Washington, USA; Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
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Kovach CP, Gunzburger EC, Morrison JT, Valle JA, Doll JA, Waldo SW. Influence of Major Adverse Events on Procedural Selection for Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment Reporting and Tracking Program. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100460. [PMID: 39132338 PMCID: PMC11307526 DOI: 10.1016/j.jscai.2022.100460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 08/13/2024]
Abstract
Background Public reporting of percutaneous coronary intervention (PCI) outcomes has been associated with risk-averse attitudes, and pressure to avoid negative outcomes may hinder the care of high-risk patients referred for PCI in public reporting environments. It is unknown whether the occurrence of PCI-related major adverse events (MAEs) influences future case selection in nonpublic reporting environments. Here, we describe trends in PCI case selection among patients undergoing coronary angiography following MAEs in Veterans Affairs (VA) cardiac catheterization laboratories participating in a mandatory internal quality improvement program without public reporting of outcomes. Methods Patients who underwent coronary angiography between October 1, 2010, and September 30, 2018, were identified and stratified by VA 30-day PCI mortality risk. The association between MAEs and changes in the proportion of patients proceeding from coronary angiography to PCI within 14 days was assessed. Results A total of 251,526 patients and 913 MAEs were included in the analysis. For each prespecified time period of 1, 2, and 4 weeks following an MAE, there were no significant changes in the proportion of patients undergoing coronary angiography who proceeded to PCI within 14 days for the overall cohort and for each tercile of VA 30-day PCI mortality risk. Conclusions There were no deviations from routine PCI referral practices following MAEs in this analysis of VA cardiac catheterization laboratories. Nonpublic reporting environments and quality improvement programs may be influential in mitigating PCI risk-aversion behaviors.
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Affiliation(s)
- Christopher P. Kovach
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
| | - Elise C. Gunzburger
- Center of Innovation, Rocky Mountain Veterans Affairs Medical Center, Aurora, Colorado
- Rocky Mountain Veterans Affairs Medical Center, Aurora, Colorado
| | - Justin T. Morrison
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado
| | - Javier A. Valle
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado
- Michigan Heart and Vascular Institute, Ann Arbor, Michigan
| | - Jacob A. Doll
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
- Clinical Assessment Reporting and Tracking Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
- Puget Sound Veterans Affairs Health Care System, Seattle, Washington
| | - Stephen W. Waldo
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado
- Center of Innovation, Rocky Mountain Veterans Affairs Medical Center, Aurora, Colorado
- Rocky Mountain Veterans Affairs Medical Center, Aurora, Colorado
- Clinical Assessment Reporting and Tracking Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
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