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Gaudino M, Pocock S, Rockhold F, Bhatt DL. Reporting Extended Follow-Up in Cardiovascular Clinical Trials. J Am Coll Cardiol 2023; 82:2246-2250. [PMID: 38030354 DOI: 10.1016/j.jacc.2023.09.827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/15/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Mario Gaudino
- Department of Cardio-Thoracic Surgery, Cornell Medicine, New York, New York, USA.
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Frank Rockhold
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
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2
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Li R, Huddleston S. Development of Comorbidity Index for in-hospital mortality for patients who underwent coronary artery revascularization. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:678-685. [PMID: 37987738 DOI: 10.23736/s0021-9509.23.12833-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
BACKGROUND For myocardial revascularization, coronary artery bypass grafting (CAGB) and percutaneous coronary intervention (PCI) are two common modalities but with high in-hospital mortality. A Comorbidity Index is useful to predict mortality or can be used with other covariates to develop point-scoring systems. This study aimed to develop specific comorbidity indices for patients who underwent coronary artery revascularization. METHODS Patients who underwent CABG or PCI were identified in the National Inpatient Sample database between Q4 2015-2020. Patients of age <40 were excluded for congenital heart defects. Patients were randomly sampled into experimental (70%) and validation (30%) groups. Thirty-eight Elixhauser comorbidities were identified and included in multivariable regression to discriminate in-hospital mortality. Weight for each comorbidity was assigned and single indices, Li CABG Mortality Index (LCMI) and Li PCI Mortality Index (LPMI), were developed. RESULTS Mortality discrimination by LCMI approached adequacy (c-statistic=0.691, 95% CI=0.682-0.701) and was comparable to multivariable regression with comorbidities (c-statistic=0.685, 95% CI=0.675-0.694). LCMI discrimination performed significantly better than Elixhauser Comorbidity Index (ECI) (c-statistic=0.621, 95% CI=0.611-0.631) and can be further improved by adjusting age (c-statistic=0.721, 95% CI=0.712-0.730). All models were well-calibrated (Brier score=0.021-0.022). LPMI moderately discriminated in-hospital mortality (c-statistic=0.666, 95% CI=0.660-0.672) and performed significantly better than ECI (c-statistic=0.610, 95% CI=0.604-0.616). LPMI performed better than the all-comorbidity multivariable regression (c-statistic=0.658, 95% CI=0.652-0.663). After age adjustment, LPMI discrimination was significantly increased and was approaching adequacy (c-statistic=0.695, 95% CI=0.690-0.701). All models were well-calibrated (Brier score=0.025-0.026). CONCLUSIONS LCMI and LPMI effectively discriminated and predicted in-hospital mortality. These indices were validated and performed superior to ECI. These indices can standardize comorbidity measurement as alternatives to ECI to help replicate and compare results across studies.
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Affiliation(s)
- Renxi Li
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA -
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA -
| | - Stephen Huddleston
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
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Protty MB, Valenzuela T, Sharaf A, Shome J, Hasan S, Chase A, UlHaq Z, Ionescu A, Khurana A, Jenkins G, Obaid DR, Choudhury A, Hailan A. Predictors of 1- and 12-month mortality in bifurcation coronary intervention: a contemporary perspective. Future Cardiol 2023; 19:353-361. [PMID: 37449460 DOI: 10.2217/fca-2023-0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Aim: Bifurcation-PCI is performed frequently, although without extensive evidence to back up a definitive solution for its complexity. We set out to identify factors associated with 1- and 12-month mortality after bifurcation-PCI between 2017 and 2021 in our tertiary center in Wales, UK. Results: Of 732 bifurcation PCI cases (mean age 69; 25% female), 67% were in ACS, 42% were left main PCI and 25.3% involved two-stent strategy. 30-day and 12-month mortality were 1.9 and 8.2%, respectively. Age, diabetes, smoking and renal failure are associated with mortality after bifurcation-PCI, while the choice between provisional and 2-stent strategies did not impact mortality/TLR. Conclusion: Awareness of 'real-world' outcomes of bifurcation-PCI should be used for appropriate patient selection, technique planning and procedural consent.
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Affiliation(s)
- Majd B Protty
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
- Systems Immunity University Research Institute, Cardiff University, Cardiff, CF14 4XN, UK
| | - Tom Valenzuela
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Ahmed Sharaf
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Joy Shome
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Saad Hasan
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Alexander Chase
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
- Swansea University Medical School, Swansea, SA1 8EN, UK
| | - Zia UlHaq
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Adrian Ionescu
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
- Swansea University Medical School, Swansea, SA1 8EN, UK
| | - Ayush Khurana
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Geraint Jenkins
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Daniel R Obaid
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
- Swansea University Medical School, Swansea, SA1 8EN, UK
| | - Anirban Choudhury
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
- Swansea University Medical School, Swansea, SA1 8EN, UK
| | - Ahmed Hailan
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
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4
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Li R. Development of Comorbidity Index for In-hospital Mortality for Patients Underwent Coronary Artery Revascularization. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.08.23288311. [PMID: 37090644 PMCID: PMC10120802 DOI: 10.1101/2023.04.08.23288311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Background For myocardial revascularization, coronary artery bypass grafting (CAGB) and percutaneous coronary intervention (PCI) are two common modalities but with high in-hospital mortality. A comorbidity index is useful to predict mortality or can be used with other covariates to develop point-scoring systems. This study aimed to develop specific comorbidity indices for patients who underwent coronary artery revascularization. Methods Patients who underwent CABG or PCI were identified in the National Inpatient Sample database between Q4 2015-2020. Patients of age<40 were excluded for congenital heart defects. Patients were randomly sampled into experimental (70%) and validation (30%) groups. Thirty-eight Elixhauser comorbidities were identified and included in multivariable regression to predict in-hospital mortality. Weight for each comorbidity was assigned and single indices, Li CABG Mortality Index (LCMI) and Li PCI Mortality Index (LPMI), were developed. Results Mortality prediction by LCMI approached adequacy ( c -statistic=0.691, 95% CI=0.682-0.701) and was comparable to multivariable regression with comorbidities ( c -statistic=0.685, 95% CI=0.675-0.694). LCMI prediction performed significantly better than Elixhauser Comorbidity Index (ECI) ( c -statistic=0.621, 95% CI=0.611-0.631) and can be further improved by adjusting age ( c -statistic=0.721, 95% CI=0.712-0.730). LPMI moderately predicted in-hospital mortality ( c -statistic=0.666, 95% CI=0.660-0.672) and performed significantly better than ECI ( c -statistic=0.610, 95% CI=0.604-0.616). LPMI performed better than the all-comorbidity multivariable regression ( c -statistic=0.658, 95% CI=0.652-0.663). After age adjustment, LPMI prediction was significantly increased and was approaching adequacy ( c -statistic=0.695, 95% CI=0.690-0.701). Conclusions LCMI and LPMI effectively predicted in-hospital mortality. These indices were validated and performed superior to ECI. The adjustment of age increased their predictive power to adequacy, implicating potential clinical application.
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Tung ML, Nathan AS, Hirshfeld JW. Short-Term Mortality After Percutaneous Coronary Intervention-It Ain't Over When It's Over. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100573. [PMID: 39129809 PMCID: PMC11308001 DOI: 10.1016/j.jscai.2022.100573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 08/13/2024]
Affiliation(s)
- Monica L. Tung
- Cardiovascular Medicine Division at the Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashwin S. Nathan
- Cardiovascular Medicine Division at the Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John W. Hirshfeld
- Cardiovascular Medicine Division at the Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Sielski J, Jóźwiak MA, Kaziród-Wolski K, Siudak Z, Jóźwiak M. Impact of Air Pollution and COVID-19 Infection on Periprocedural Death in Patients with Acute Coronary Syndrome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16654. [PMID: 36554535 PMCID: PMC9778735 DOI: 10.3390/ijerph192416654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/22/2022] [Accepted: 12/09/2022] [Indexed: 06/17/2023]
Abstract
Air pollution and COVID-19 infection affect the pathogenesis of cardiovascular disease. The impact of these factors on the course of ACS treatment is not well defined. The purpose of this study was to evaluate the effects of air pollution, COVID-19 infection, and selected clinical factors on the occurrence of perioperative death in patients with acute coronary syndrome (ACS) by developing a neural network model. This retrospective study included 53,076 patients with ACS from the ORPKI registry (National Registry of Invasive Cardiology Procedures) including 2395 COVID-19 (+) patients and 34,547 COVID-19 (-) patients. The neural network model developed included 57 variables, had high performance in predicting perioperative patient death, and had an error risk of 0.03%. Based on the analysis of the effect of permutation on the variable, the variables with the greatest impact on the prediction of perioperative death were identified to be vascular access, critical stenosis of the left main coronary artery (LMCA) or left anterior descending coronary artery (LAD). Air pollutants and COVID-19 had weaker effects on end-point prediction. The neural network model developed has high performance in predicting the occurrence of perioperative death. Although COVID-19 and air pollutants affect the prediction of perioperative death, the key predictors remain vascular access and critical LMCA or LAD stenosis.
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Affiliation(s)
- Janusz Sielski
- Collegium Medicum, Jan Kochanowski University in Kielce, al. IX Wieków Kielc 19A, 25-369 Kielce, Poland
| | | | - Karol Kaziród-Wolski
- Collegium Medicum, Jan Kochanowski University in Kielce, al. IX Wieków Kielc 19A, 25-369 Kielce, Poland
| | - Zbigniew Siudak
- Collegium Medicum, Jan Kochanowski University in Kielce, al. IX Wieków Kielc 19A, 25-369 Kielce, Poland
| | - Marek Jóźwiak
- Institute of Geography and Environmental Sciences, Jan Kochanowski University in Kielce, Uniwersytecka 7, 25-406 Kielce, Poland
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7
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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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8
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Lim MJR, Zheng Y, Soh RYH, Foo QXJ, Djohan AH, Nga Diong Weng V, Ho JSY, Yeo TT, Sim HW, Yeo TC, Tan HC, Chan MYY, Loh JPY, Sia CH. Symptomatic intracerebral hemorrhage after non-emergency percutaneous coronary intervention: Incidence, risk factors, and association with cardiovascular outcomes. Front Cardiovasc Med 2022; 9:936498. [PMID: 36186990 PMCID: PMC9524143 DOI: 10.3389/fcvm.2022.936498] [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: 05/05/2022] [Accepted: 08/29/2022] [Indexed: 12/04/2022] Open
Abstract
Objective To investigate the incidence, risk factors, and association with cardiovascular outcomes of patients who developed symptomatic intracerebral hemorrhage (ICH) after non-emergency percutaneous coronary intervention (PCI). Methods We conducted a single-institution retrospective study of patients who developed symptomatic ICH after non-emergency PCI. To identify associations between clinical variables and outcomes, Cox-proportional hazards regression models were constructed. Outcomes analyzed include (1) all-cause mortality, (2) acute ischemic stroke (AIS) or transient ischemic attack (TIA), and (3) major adverse cardiovascular events (MACE). Results A total of 1,732 patients were included in the analysis. The mean (±SD) age was 61.1 (±11.3) years, and 1,396 patients (80.6%) were male. The cumulative incidence of symptomatic ICH after non-emergency PCI was 1.3% (22 patients). Age, chronic kidney disease, and prior coronary artery bypass graft surgery were independently associated with a higher risk of ICH after PCI, while hyperlipidemia was independently associated with a lower risk of ICH after PCI. ICH after PCI was independently associated with a higher risk of all-cause mortality and AIS or TIA after PCI. Conclusion Patients who are older, who have chronic kidney disease, and who have had prior coronary artery bypass graft surgery should be monitored for symptomatic ICH after non-emergency PCI.
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Affiliation(s)
- Mervyn Jun Rui Lim
- Division of Neurosurgery, National University Health System, Singapore, Singapore
- *Correspondence: Mervyn Jun Rui Lim
| | - Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Rodney Yu-Hang Soh
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Qi Xuan Joel Foo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | | | - Jamie Sin-Ying Ho
- Academic Foundation Programme, North Middlesex University Hospital Trust, London, United Kingdom
| | - Tseng Tsai Yeo
- Division of Neurosurgery, National University Health System, Singapore, Singapore
| | - Hui-Wen Sim
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Huay-Cheem Tan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mark Yan-Yee Chan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joshua Ping-Yun Loh
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Truesdell AG, Cilia L, Serhal M. Just in Case, Just Because, or Just Right? Circ Cardiovasc Interv 2022; 15:e011999. [PMID: 35580201 DOI: 10.1161/circinterventions.122.011999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Lindsey Cilia
- Division of Cardiology, Massachusetts General Hospital, Boston (L.C., M.S.).,Division of Cardiology, Brigham and Women's Hospital, Boston, MA (L.C.)
| | - Maya Serhal
- Division of Cardiology, Massachusetts General Hospital, Boston (L.C., M.S.)
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10
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Kondo T. Report on the nature, characteristics, and outcomes of the Japanese healthcare system. Glob Health Med 2022; 4:37-44. [PMID: 35291196 PMCID: PMC8884037 DOI: 10.35772/ghm.2021.01097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/14/2021] [Accepted: 12/22/2021] [Indexed: 06/14/2023]
Abstract
In Japan, healthcare takes a "patient-centeredness" approach to prioritize providing rational medicine for patients under the initiative of medical doctors. This approach to healthcare is based on the concept that patients should receive the correct diagnosis and optimal treatment. The present report aims to provide an overview of the specific characteristics of healthcare in Japan to healthcare management professionals in other countries. We introduce the systems within Japan's healthcare framework, particularly "medical team approach", "nutrition management", and "infection controls", as well as treatment results in Japan using objective data to inform medical doctors in management positions in other parts of the world. Collectively, these three healthcare systems comprise the "patient-centeredness" philosophy through which Japanese healthcare professionals perceive ideal patient care and act accordingly. These healthcare systems are unique to Japan and were developed in accordance with the specific framework of Japanese history, systems, and culture. This report presents the effects of "patient-centeredness" healthcare based on treatment results and performance data by making a quantitative and qualitative comparison with healthcare in Europe and the USA. Further objective evaluation revealed that Japan demonstrates positive treatment results that are comparable to those of Europe and the USA due to its "patient-centeredness" rational medical system and the availability of the "correct diagnosis and optimal treatment". These findings introduce Japan's "patient-centeredness" medical and healthcare system with a view of informing and guiding improvements in the healthcare quality of other countries and promoting future international collaborations.
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Affiliation(s)
- Tatsuya Kondo
- Address correspondence to:Tatsuya Kondo, Medical Excellence JAPAN, Ichibancho Hougenzaka Bldg. 3F, 13 Ichibancho, Chiyoda-ku, Tokyo 102- 0082, Japan. E-mail:
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11
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Moroni F, Gurm HS, Gertz Z, Abbate A, Azzalini L. In-hospital death among patients undergoing percutaneous coronary intervention: A root-cause analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 40S:8-13. [DOI: 10.1016/j.carrev.2022.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/30/2021] [Accepted: 01/20/2022] [Indexed: 11/03/2022]
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12
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Doll JA, Nelson AJ, Kaltenbach LA, Wojdyla D, Waldo SW, Rao SV, Wang TY. Percutaneous Coronary Intervention Operator Profiles and Associations With In-Hospital Mortality. Circ Cardiovasc Interv 2021; 15:e010909. [PMID: 34847693 DOI: 10.1161/circinterventions.121.010909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous coronary intervention is performed by operators with differing experience, technique, and case mix. It is unknown if operator practice patterns impact patient outcomes. We sought to determine if a cluster algorithm can identify distinct profiles of percutaneous coronary intervention operators and if these profiles are associated with patient outcomes. METHODS Operators performing at least 25 annual procedures between 2014 and 2018 were clustered using an agglomerative hierarchical clustering algorithm. Risk-adjusted in-hospital mortality was compared between clusters. RESULTS We identified 4 practice profiles among 7706 operators performing 2 937 419 procedures. Cluster 1 (n=3345) demonstrated case mix and practice patterns similar to the national median. Cluster 2 (n=1993) treated patients with lower clinical acuity and were less likely to use intracoronary diagnostics, atherectomy, and radial access. Cluster 3 (n=1513) had the lowest case volume, were more likely to work at rural hospitals, and cared for a higher proportion of patients with ST-segment-elevation myocardial infarction and cardiogenic shock. Cluster 4 (n=855) had the highest case volume, were most likely to treat patients with high anatomic complexity and use atherectomy, intracoronary diagnostics, and mechanical support. Compared with cluster 1, adjusted in-hospital mortality was similar for cluster 2 (estimated difference, -0.03 [95% CI, -0.10 to 0.04]), higher for cluster 3 (0.14 [0.07-0.22]), and lower for cluster 4 (-0.15 [-0.24 to -0.06]). CONCLUSIONS Distinct percutaneous coronary intervention operator profiles are differentially associated with patient outcomes. A phenotypic approach to physician assessment may provide actionable feedback for quality improvement.
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Affiliation(s)
- Jacob A Doll
- Division of Cardiology, Department of Medicine, University of Washington (J.A.D.).,Section of Cardiology, VA Puget Sound Health Care System, Seattle, WA (J.A.D.)
| | - Adam J Nelson
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.)
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.)
| | - Daniel Wojdyla
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.)
| | - Stephen W Waldo
- University of Colorado School of Medicine (S.W.W.).,Department of Medicine, Rocky Mountain Regional VA Medical Center (S.W.W.).,VA CART Program, VHA Office of Quality and Patient Safety (S.W.W.)
| | - Sunil V Rao
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.).,Department of Medicine, Duke University School of Medicine (S.V.R., T.Y.W.)
| | - Tracy Y Wang
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.).,Department of Medicine, Duke University School of Medicine (S.V.R., T.Y.W.)
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13
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Biswas S, Dinh D, Duffy SJ, Brennan A, Liew D, Chan W, Cox N, Reid CM, Lefkovits J, Stub D. Characteristics and outcomes of unsuccessful percutaneous coronary intervention. Catheter Cardiovasc Interv 2021; 99:609-616. [PMID: 34331500 DOI: 10.1002/ccd.29886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/12/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To examine predictors and outcomes of unsuccessful percutaneous coronary intervention (PCI) cases in a contemporary Australian registry cohort. BACKGROUND With improvements in techniques and pharmacotherapy in PCI, more complex lesions in older patients are now being attempted. In the context of PCI performance assessment, there are limited data regarding the characteristics and outcomes of unsuccessful PCI. METHOD We prospectively collected data on patients undergoing single-lesion PCI between 2013 and 2017 who were enrolled in the multi-center Victorian Cardiac Outcomes Registry. Procedures were divided into two groups by whether or not PCI was deemed successful at the end of the procedure using a pre-specified definition. RESULTS There were 34,383 single-lesion PCI performed, of which 18,644 (54.2%) were for acute coronary syndromes. Of the study cohort, 2080 patients (6.0%) had an unsuccessful PCI - these patients were older, more likely to have previous stroke, PCI, severe left ventricular dysfunction and chronic kidney disease (all p < 0.001). The procedure was also more likely to be performed for stable angina (p < 0.001). Chronic total occlusion PCI made up 31% of unsuccessful PCI cases. Unsuccessful PCI was itself associated with higher in-hospital and 30-day mortality and MACE (all p < 0.001). 4.9% of unsuccessful PCIs led to unplanned in-hospital bypass surgery (compared to 0.2% in successful PCIs, p < 0.001). CONCLUSION Our study highlights that even in contemporary PCI practice, more than 1 in 20 PCI attempts are unsuccessful. Lack of procedural success has a strong influence on patient outcomes. Monitoring rates of unsuccessful cases is an important quality assurance tool.
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Affiliation(s)
- Sinjini Biswas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Diem Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Angela Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of General Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - William Chan
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
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14
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Nathan AS, Giri J, Fanaroff A. Reporting of Percutaneous Coronary Interventions Site-Specific Mortality-Reply. JAMA Cardiol 2021; 6:1344. [PMID: 34232256 DOI: 10.1001/jamacardio.2021.2108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ashwin S Nathan
- Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
| | - Jay Giri
- Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Alexander Fanaroff
- Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
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15
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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16
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2773] [Impact Index Per Article: 924.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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17
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Reynolds MR, Gong T, Li S, Herzog CA, Charytan DM. Cost-Effectiveness of Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease and Acute Coronary Syndromes in the US Medicare Program. J Am Heart Assoc 2021; 10:e019391. [PMID: 33787323 PMCID: PMC8174359 DOI: 10.1161/jaha.120.019391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/24/2021] [Indexed: 01/24/2023]
Abstract
Background Coronary revascularization provides important long-term clinical benefits to patients with high-risk presentations of coronary artery disease, including those with chronic kidney disease. The cost-effectiveness of coronary interventions in this setting is not known. Methods and Results We developed a Markov cohort simulation model to assess the cost-effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with chronic kidney disease who were hospitalized with acute myocardial infarction or unstable angina. Model inputs were primarily drawn from a sample of 14 300 patients identified using the Medicare 20% sample. Survival, quality-adjusted life-years, costs, and cost-effectiveness were projected over a 20-year time horizon. Multivariable models indicated higher 30-day mortality and end-stage renal disease with both PCI and CABG, and higher stroke with CABG, relative to medical therapy. However, the model projected long-term gains of 0.72 quality-adjusted life-years (0.97 life-years) for PCI compared with medical therapy, and 0.93 quality-adjusted life-years (1.32 life-years) for CABG compared with PCI. Incorporation of long-term costs resulted in incremental cost-effectiveness ratios of $65 326 per quality-adjusted life-year gained for PCI versus medical therapy, and $101 565 for CABG versus PCI. Results were robust to changes in input parameters but strongly influenced by the background costs of the population, and the time horizon. Conclusions For patients with chronic kidney disease and high-risk coronary artery disease presentations, PCI and CABG were both associated with markedly increased costs as well as gains in quality-adjusted life expectancy, with incremental cost-effectiveness ratios indicating intermediate value in health economic terms.
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Affiliation(s)
- Matthew R. Reynolds
- Lahey Hospital & Medical CenterBurlingtonMA
- Baim Institute for Clinical ResearchBostonMA
| | - Tingting Gong
- Chronic Disease Research GroupHennepin Healthcare Research InstituteMinneapolisMN
| | - Shuling Li
- Chronic Disease Research GroupHennepin Healthcare Research InstituteMinneapolisMN
| | - Charles A. Herzog
- Chronic Disease Research GroupHennepin Healthcare Research InstituteMinneapolisMN
- Department of MedicineHennepin Healthcare and University of MinnesotaMinneapolisMN
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18
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Goerne H, de la Fuente D, Cabrera M, Chaturvedi A, Vargas D, Young PM, Saboo SS, Rajiah P. Imaging Features of Complications after Coronary Interventions and Surgical Procedures. Radiographics 2021; 41:699-719. [PMID: 33798007 DOI: 10.1148/rg.2021200147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Coronary artery interventions and surgical procedures are used in the treatment of coronary artery disease and some congenital heart diseases. Cardiac and noncardiac complications can occur at variable times after these procedures, with the clinical presentation ranging from asymptomatic to devastating symptoms. Invasive coronary angiography is the reference standard modality used in the evaluation of coronary arteries, with intravascular US and optical coherence tomography providing high-resolution information regarding the vessel wall. CT is the mostly commonly used noninvasive imaging modality in the evaluation of coronary artery intervention complications and allows assessment of the stent, lumen of the stent, lumen of the coronary arteries, and extracoronary structures. MRI is limited to the evaluation of the proximal coronary arteries but allows comprehensive evaluation of the myocardium, including ischemia and infarction. The authors review the clinical symptoms and pathophysiologic and imaging features of various complications of coronary artery interventions and surgical procedures. Complications of percutaneous coronary interventions are discussed, including restenosis, thrombosis, dissection of coronary arteries or the aorta, coronary wall rupture or perforation, stent deployment failure, stent fracture, stent infection, stent migration or embolism, and reperfusion injury. Complications of several surgical procedures are reviewed, including coronary artery bypass grafting, coronary artery reimplantation procedure (for anomalous origin from opposite sinuses or the pulmonary artery or as part of surgical procedures such as arterial switching surgery and the Bentall and Cabrol procedures), coronary artery unroofing, and the Takeuchi procedure. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Harold Goerne
- From the Department of Cardiac Imaging, Imaging and Diagnostic Center CID, Americas Avenue 2016, Guadalajara, Jalisco, Mexico (H.G.); Department of Radiology, Western National Medical Center IMSS, Guadalajara, Jalisco, Mexico (H.G., D.d.l.F., M.C.); Department of Radiology, University of Rochester Medical Center, Rochester, NY (A.C.); Department of Radiology, University of Colorado Hospital, Denver, Colo (D.V.); Department of Radiology, Mayo Clinic, Rochester, Minn (P.M.Y., P.R.); and Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.S.)
| | - Diego de la Fuente
- From the Department of Cardiac Imaging, Imaging and Diagnostic Center CID, Americas Avenue 2016, Guadalajara, Jalisco, Mexico (H.G.); Department of Radiology, Western National Medical Center IMSS, Guadalajara, Jalisco, Mexico (H.G., D.d.l.F., M.C.); Department of Radiology, University of Rochester Medical Center, Rochester, NY (A.C.); Department of Radiology, University of Colorado Hospital, Denver, Colo (D.V.); Department of Radiology, Mayo Clinic, Rochester, Minn (P.M.Y., P.R.); and Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.S.)
| | - Miguel Cabrera
- From the Department of Cardiac Imaging, Imaging and Diagnostic Center CID, Americas Avenue 2016, Guadalajara, Jalisco, Mexico (H.G.); Department of Radiology, Western National Medical Center IMSS, Guadalajara, Jalisco, Mexico (H.G., D.d.l.F., M.C.); Department of Radiology, University of Rochester Medical Center, Rochester, NY (A.C.); Department of Radiology, University of Colorado Hospital, Denver, Colo (D.V.); Department of Radiology, Mayo Clinic, Rochester, Minn (P.M.Y., P.R.); and Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.S.)
| | - Abhishek Chaturvedi
- From the Department of Cardiac Imaging, Imaging and Diagnostic Center CID, Americas Avenue 2016, Guadalajara, Jalisco, Mexico (H.G.); Department of Radiology, Western National Medical Center IMSS, Guadalajara, Jalisco, Mexico (H.G., D.d.l.F., M.C.); Department of Radiology, University of Rochester Medical Center, Rochester, NY (A.C.); Department of Radiology, University of Colorado Hospital, Denver, Colo (D.V.); Department of Radiology, Mayo Clinic, Rochester, Minn (P.M.Y., P.R.); and Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.S.)
| | - Daniel Vargas
- From the Department of Cardiac Imaging, Imaging and Diagnostic Center CID, Americas Avenue 2016, Guadalajara, Jalisco, Mexico (H.G.); Department of Radiology, Western National Medical Center IMSS, Guadalajara, Jalisco, Mexico (H.G., D.d.l.F., M.C.); Department of Radiology, University of Rochester Medical Center, Rochester, NY (A.C.); Department of Radiology, University of Colorado Hospital, Denver, Colo (D.V.); Department of Radiology, Mayo Clinic, Rochester, Minn (P.M.Y., P.R.); and Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.S.)
| | - Phillip M Young
- From the Department of Cardiac Imaging, Imaging and Diagnostic Center CID, Americas Avenue 2016, Guadalajara, Jalisco, Mexico (H.G.); Department of Radiology, Western National Medical Center IMSS, Guadalajara, Jalisco, Mexico (H.G., D.d.l.F., M.C.); Department of Radiology, University of Rochester Medical Center, Rochester, NY (A.C.); Department of Radiology, University of Colorado Hospital, Denver, Colo (D.V.); Department of Radiology, Mayo Clinic, Rochester, Minn (P.M.Y., P.R.); and Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.S.)
| | - Sachin S Saboo
- From the Department of Cardiac Imaging, Imaging and Diagnostic Center CID, Americas Avenue 2016, Guadalajara, Jalisco, Mexico (H.G.); Department of Radiology, Western National Medical Center IMSS, Guadalajara, Jalisco, Mexico (H.G., D.d.l.F., M.C.); Department of Radiology, University of Rochester Medical Center, Rochester, NY (A.C.); Department of Radiology, University of Colorado Hospital, Denver, Colo (D.V.); Department of Radiology, Mayo Clinic, Rochester, Minn (P.M.Y., P.R.); and Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.S.)
| | - Prabhakar Rajiah
- From the Department of Cardiac Imaging, Imaging and Diagnostic Center CID, Americas Avenue 2016, Guadalajara, Jalisco, Mexico (H.G.); Department of Radiology, Western National Medical Center IMSS, Guadalajara, Jalisco, Mexico (H.G., D.d.l.F., M.C.); Department of Radiology, University of Rochester Medical Center, Rochester, NY (A.C.); Department of Radiology, University of Colorado Hospital, Denver, Colo (D.V.); Department of Radiology, Mayo Clinic, Rochester, Minn (P.M.Y., P.R.); and Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.S.)
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19
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Hartung P, Jobs A, Thiele H. Risikostratifizierung des NSTE-ACS. AKTUELLE KARDIOLOGIE 2021. [DOI: 10.1055/a-1341-6712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungMit zunehmender Verbesserung der Prognose der NSTE-ACS-Patientenkollektive in den letzten Jahren spielt eine standardisierte, schnelle und gute diskriminierende Risikostratifizierung eine erhebliche Rolle. Verschiedene Merkmale des langfristig erwartbaren ischämischen Risikos, wie z.B. klinische Parameter, EKG-Indikatoren, Biomarker und klinische Scores, werden zusammen mit dem individuellen Blutungsrisiko erfasst und integriert. So ist z.B. die absolute Höhe der Troponin-Konzentration prädiktiv für die Gesamtletalität. Der GRACE-Risk-Score wird nicht nur zusätzlich zur objektiven Risikostratifizierung empfohlen, sondern ein Punktwert >140 ist eines der Kriterien für eine frühe Koronarangiografie innerhalb von 24 Stunden. Die Abschätzung des Blutungsrisikos entsprechend der ARC-HBR-Kriterien hat einen Einfluss auf das antithrombotische Therapieregime.
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Affiliation(s)
- Philipp Hartung
- Universitätsklinik für Kardiologie, Herzzentrum Leipzig, Leipzig, Deutschland
| | - Alexander Jobs
- Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland
- Universitätsklinik für Kardiologie, Herzzentrum Leipzig, Leipzig, Deutschland
- Deutsches Zentrum für Herz-Kreislauf-Forschung e. V., DZHK, Berlin, Deutschland
| | - Holger Thiele
- Universitätsklinik für Kardiologie, Herzzentrum Leipzig, Leipzig, Deutschland
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20
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Nair AR, Johnson EA, Yang HJ, Cokic I, Francis J, Dharmakumar R. Reperfused hemorrhagic myocardial infarction in rats. PLoS One 2020; 15:e0243207. [PMID: 33264359 PMCID: PMC7710030 DOI: 10.1371/journal.pone.0243207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 11/17/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intramyocardial hemorrhage following reperfusion is strongly associated with major adverse cardiovascular events in myocardial infarction (MI) patients; yet the mechanisms contributing to these outcomes are not well understood. Large animal models have been used to investigate intramyocardial hemorrhage, but they are exorbitantly expensive and difficult to use for mechanistic studies. In contrast, rat models are widely used to investigate mechanistic aspects of cardiovascular physiology, but a rat model that consistently recapitulates the characteristics of an hemorrhagic MI does not exist. To bridge this gap, we investigated the physiological conditions of MI that would create intramyocardial hemorrhage in rats so that a reliable model of hemorrhagic MI would become available for basic research. METHODS & RESULTS Sprague-Dawley rats underwent either a 90-minute (90-min) ischemia and then reperfusion (I/R) (n = 22) or 30-minute (30-min) I/R (n = 18) of the left anterior descending coronary artery. Sham rats (n = 12) were used as controls. 90-min I/R consistently yielded hemorrhagic MI, while 30-min I/R consistently yielded non-hemorrhagic MI. Twenty-four hours post-reperfusion, ex-vivo late-gadolinium-enhancement (LGE) and T2* cardiac MRI performed on excised hearts from 90-min I/R rats revealed colocalization of iron deposits within the scarred tissue; however, in 30-min I/R rats scar was evident on LGE but no evidence of iron was found on T2* CMR. Histological studies verified tissue damage (H&E) detected on LGE and the presence of iron (Perl's stain) observed on T2*-CMR. At week 4 post-reperfusion, gene and protein expression of proinflammatory markers (TNF-α, IL-1β and MMP-9) were increased in the 90-min I/R group when compared to 30-min I/R groups. Further, transmission electron microscopy performed on 90-min I/R myocardium that were positive for iron on T2* CMR and Perl's stain showed accumulation of granular iron particles within the phagosomes. CONCLUSION Ischemic time prior to reperfusion is a critical factor in determining whether a MI is hemorrhagic or non-hemorrhagic in rats. Specifically, a period of 90-min of ischemia prior to reperfusion can produce rat models of hemorrhagic MI, while 30-minutes of ischemia prior to reperfusion can ensure that the MIs are non-hemorrhagic. Hemorrhagic MIs in rats result in marked increase in iron deposition, proinflammatory burden and adverse left-ventricular remodeling compared to rats with non-hemorrhagic MIs.
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Affiliation(s)
- Anand R. Nair
- Cedars-Sinai Medical Center, Department of Biomedical Sciences, Biomedical Imaging Research Institute, Los Angeles, CA, United States of America
| | - Eric A. Johnson
- Cedars-Sinai Medical Center, Department of Biomedical Sciences, Biomedical Imaging Research Institute, Los Angeles, CA, United States of America
- Department of Bioengineering, University of California, Los Angeles, CA, United States of America
| | - Hsin-Jung Yang
- Cedars-Sinai Medical Center, Department of Biomedical Sciences, Biomedical Imaging Research Institute, Los Angeles, CA, United States of America
| | - Ivan Cokic
- Cedars-Sinai Medical Center, Department of Biomedical Sciences, Biomedical Imaging Research Institute, Los Angeles, CA, United States of America
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, CA, United States of America
| | - Joseph Francis
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, United States of America
| | - Rohan Dharmakumar
- Cedars-Sinai Medical Center, Department of Biomedical Sciences, Biomedical Imaging Research Institute, Los Angeles, CA, United States of America
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, CA, United States of America
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21
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Gaudino M, Hameed I, Farkouh ME, Rahouma M, Naik A, Robinson NB, Ruan Y, Demetres M, Biondi-Zoccai G, Angiolillo DJ, Bagiella E, Charlson ME, Benedetto U, Ruel M, Taggart DP, Girardi LN, Bhatt DL, Fremes SE. Overall and Cause-Specific Mortality in Randomized Clinical Trials Comparing Percutaneous Interventions With Coronary Bypass Surgery: A Meta-analysis. JAMA Intern Med 2020; 180:1638-1646. [PMID: 33044497 PMCID: PMC7551235 DOI: 10.1001/jamainternmed.2020.4748] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Mortality is a common outcome in trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG). Controversy exists regarding whether all-cause mortality or cardiac mortality is preferred as a study end point, because noncardiac mortality should be unrelated to the treatment. OBJECTIVE To evaluate the difference in all-cause and cause-specific mortality in randomized clinical trials (RCTs) comparing PCI with CABG for the treatment of patients with coronary artery disease. DATA SOURCES MEDLINE (1946 to the present), Embase (1974 to the present), and the Cochrane Library (1992 to the present) databases were searched on November 24, 2019. Reference lists of included articles were also searched, and additional studies were included if appropriate. STUDY SELECTION Articles were considered for inclusion if they were in English, were RCTs comparing PCI with drug-eluting or bare-metal stents and CABG for the treatment of coronary artery disease, and reported mortality and/or cause-specific mortality. Trials of PCI involving angioplasty without stenting were excluded. For each included trial, the publication with the longest follow-up duration for each outcome was selected. DATA EXTRACTION AND SYNTHESIS For data extraction, all studies were reviewed by 2 independent investigators, and disagreements were resolved by a third investigator in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Data were pooled using fixed- and random-effects models. MAIN OUTCOMES AND MEASURES The primary outcomes were all-cause and cause-specific (cardiac vs noncardiac) mortality. Subgroup analyses were performed for PCI trials using drug-eluting vs bare-metal stents and for trials involving patients with left main disease. RESULTS Twenty-three unique trials were included involving 13 620 unique patients (6829 undergoing PCI and 6791 undergoing CABG; men, 39.9%-99.0% of study populations; mean age range, 60.0-71.0 years). The weighted mean (SD) follow-up was 5.3 (3.6) years. Compared with CABG, PCI was associated with a higher rate of all-cause (incidence rate ratio, 1.17; 95% CI, 1.05-1.29) and cardiac (incidence rate ratio, 1.24; 95% CI, 1.05-1.45) mortality but also noncardiac mortality (incidence rate ratio, 1.19; 95% CI, 1.00-1.41). CONCLUSIONS AND RELEVANCE Percutaneous coronary intervention was associated with higher all-cause, cardiac, and noncardiac mortality compared with CABG at 5 years. The significantly higher noncardiac mortality associated with PCI suggests that even noncardiac deaths after PCI may be procedure related and supports the use of all-cause mortality as the end point for myocardial revascularization trials.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Irbaz Hameed
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.,Section of Cardiothoracic Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Michael E Farkouh
- Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Ajita Naik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Yongle Ruan
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Michelle Demetres
- Samuel J. Wood Library and C. V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, New York
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Napoli, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mary E Charlson
- Division of General Internal Medicine, Weill Cornell Medical College, New York, New York
| | - Umberto Benedetto
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David P Taggart
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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22
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Grines CL, Tummala P. Another nail in the coffin for the use of risk-adjusted mortality after percutaneous coronary intervention as a quality indicator. Catheter Cardiovasc Interv 2020; 96:741-742. [PMID: 33085197 DOI: 10.1002/ccd.29289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/17/2020] [Indexed: 11/12/2022]
Affiliation(s)
- Cindy L Grines
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia
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23
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Gaddam A, Ajibawo T, Ravat V, Yomi T, Patel RS. In-Hospital Mortality Risk in Post-Percutaneous Coronary Interventions Cancer Patients: A Nationwide Analysis of 1.1 Million Heart Disease Patients. Cureus 2020; 12:e9071. [PMID: 32782887 PMCID: PMC7413566 DOI: 10.7759/cureus.9071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives The primary goal of this inpatient study is to assess the risk of in-hospital mortality due to cancer and chronic comorbidities in post-percutaneous coronary intervention (PCI) patients. Methods We conducted a retrospective cross-sectional study, including 1,131,415 adult patients (age +18 years) by using the Nationwide Inpatient Sample (NIS) from 2012 to 2014. These patients underwent PCI, and they were further sub-grouped by the co-diagnosis of cancer. Logistic regression analysis was used to evaluate the risk of association between comorbid cancer and in-hospital mortality in post-PCI inpatients. Results Most PCI inpatients with cancer were older adults (mean age 70.6 years), males (71.8%), and white (80.6%). Post-PCI mortality risk was 1.28 times higher in females (95% CI 1.235 - 1.335) as compared to males. Coagulopathy and anemias significantly increased the risk of post-PCI mortality by three times (95% CI 2.837 - 3.250) and 1.6 times (95% CI 1.534 - 1.692), respectively. Comorbid cancer was associated with an increased risk of in-hospital mortality in post-PCI patients by 1.9 times (95% CI 1.686 - 2.086) after controlling for demographic confounders and chronic comorbidities. Conclusion Our analysis showed that cancer is an independent risk factor for in-hospital mortality after PCI. This association calls for an integrated care model in the management of a complex patient population with cancer and other comorbidities requiring more vigilance and aggressive management.
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Affiliation(s)
- Anusha Gaddam
- Internal Medicine, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, IND
| | - Temitope Ajibawo
- Internal Medicine, Brookdale University Hospital Medical Center, New York City, USA
| | | | - Timiiye Yomi
- Medicine, University of Benin School of Medicine, Benin City, NGA
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24
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Doll JA, Hira RS, Kearney KE, Kandzari DE, Riley RF, Marso SP, Grantham JA, Thompson CA, McCabe JM, Karmpaliotis D, Kirtane AJ, Lombardi W. Management of Percutaneous Coronary Intervention Complications: Algorithms From the 2018 and 2019 Seattle Percutaneous Coronary Intervention Complications Conference. Circ Cardiovasc Interv 2020; 13:e008962. [PMID: 32527193 DOI: 10.1161/circinterventions.120.008962] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Complications of percutaneous coronary intervention (PCI) may have significant impact on patient survival and healthcare costs. PCI procedural complexity and patient risk are increasing, and operators must be prepared to recognize and treat complications, such as perforations, dissections, hemodynamic collapse, no-reflow, and entrapped equipment. Unfortunately, few resources exist to train operators in PCI complication management. Uncertainty regarding complication management could contribute to the undertreatment of patients with high-complexity coronary disease. We, therefore, coordinated the Learning From Complications: How to Be a Better Interventionalist courses to disseminate the collective experience of high-volume PCI operators with extensive experience in chronic total occlusion and high-risk PCI. From these conferences in 2018 and 2019, we developed algorithms that emphasize early recognition, effective treatment, and team-based care of PCI complications. We think that an algorithmic approach will result in a logical and systematic response to life-threatening complications. This construct may be useful for operators who plan to perform complex PCI procedures.
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Affiliation(s)
- Jacob A Doll
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.).,VA Puget Sound Health Care System, Seattle, WA (J.A.D.)
| | - Ravi S Hira
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.)
| | - Kathleen E Kearney
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.)
| | | | - Robert F Riley
- The Christ Hospital Health Network, Cincinnati, OH (R.F.R.)
| | - Steven P Marso
- HCA Midwest Health Heart and Vascular Institute, Overland Park, KS (S.P.M.)
| | - James A Grantham
- Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.G.).,University of Missouri-Kansas City, Kansas City, MO (J.A.G.)
| | | | - James M McCabe
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.)
| | | | - Ajay J Kirtane
- Columbia University Medical Center, New York, NY (D.K., A.J.K.)
| | - William Lombardi
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.)
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Morrison J, Plomondon ME, O'Donnell CI, Giri J, Doll JA, Valle JA, Waldo SW. Perceptions of Public and Nonpublic Reporting of Interventional Cardiology Outcomes and Its Impact on Practice: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. J Am Heart Assoc 2019; 8:e014212. [PMID: 31711384 PMCID: PMC6915263 DOI: 10.1161/jaha.119.014212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Physicians have expressed significant mistrust with public reporting of interventional cardiology outcomes. Similar data are not available on alternative reporting structures, including nonpublic quality improvement programs with internally distributed measures of interventional quality. We thus sought to evaluate the perceptions of public and nonpublic reporting of interventional cardiology outcomes and its impact on clinical practice. Methods and Results A standardized survey was distributed to 218 interventional cardiologists in the Veterans Affairs Healthcare System, with responses received from 62 (28%). The majority of respondents (90%) expressed some or a great deal of trust in the analytic methods used to generate reports in a nonpublic quality improvement system within Veterans Affairs, while a minority (35%) expressed similar trust in the analytic methods in a public reporting system that operates outside Veterans Affairs (P<0.001). Similarly, a minority of respondents (44%) felt that in‐hospital and 30‐day mortality accurately reflected interventional quality in a nonpublic quality improvement system, though a smaller proportion of survey participants (15%) felt that the same outcome reflected procedural quality in public reporting systems (P<0.001). Despite these sentiments, the majority of operators did not feel pressured to avoid (82% and 75%; P=0.383) or perform (72% and 63%; P=0.096) high‐risk procedures within or outside Veterans Affairs. Conclusions Interventional cardiologists express greater trust in analytic methods and clinical outcomes reported in a nonpublic quality improvement program than external public reporting environments. The majority of physicians did not feel pressured to avoid or perform high‐risk procedures, which may improve access to interventional care among high‐risk patients.
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Affiliation(s)
- Justin Morrison
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO
| | | | | | - Jay Giri
- University of Pennsylvania School of Medicine Philadelphia PA
| | | | - Javier A Valle
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO
| | - Stephen W Waldo
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO
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Sandhu AT, Kohsaka S, Bhattacharya J, Fearon WF, Harrington RA, Heidenreich PA. Association Between Current and Future Annual Hospital Percutaneous Coronary Intervention Mortality Rates. JAMA Cardiol 2019; 4:1077-1083. [PMID: 31532454 DOI: 10.1001/jamacardio.2019.3221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Multiple states publicly report a hospital's risk-adjusted mortality rate for percutaneous coronary intervention (PCI) as a quality measure. However, whether reported annual PCI mortality is associated with a hospital's future performance is unclear. Objective To evaluate the association between reported risk-adjusted hospital PCI-related mortality and a hospital's future PCI-related mortality. Design, Setting, and Participants This study used data from the New York Percutaneous Intervention Reporting System from January 1, 1998, to December 31, 2016, to assess hospitals that perform PCI. Exposures Public-reported, risk-adjusted, 30-day mortality after PCI. Main Outcomes and Measures The primary analysis evaluated the association between a hospital's reported risk-adjusted PCI-related mortality and future PCI-related mortality. The correlation between a hospital's observed to expected (O/E) PCI-related mortality rates each year and future O/E mortality ratios was assessed. Multivariable linear regression was used to examine the association between index year O/E mortality and O/E mortality in subsequent years while adjusting for PCI volume and patient severity. Results This study included 67 New York hospitals and 960 hospital-years. Hospitals with low PCI-related mortality (O/E mortality ratio, ≤1) and high mortality (O/E mortality ratio, >1) had inverse associations between their O/E mortality ratio in the index year and the subsequent change in the ratio (hospitals with low mortality, r = -0.45; hospitals with high mortality, r = -0.60). Little of the variation in risk-adjusted mortality was explained by prior performance. An increase in the O/E mortality ratio from 1.0 to 2.0 in the index year was associated with a higher O/E mortality ratio of only 0.15 (95% CI, 0.02-0.27) in the following year. Conclusions and Relevance At hospitals with high or low PCI-related mortality rates, the rates largely regressed to the mean the following year. A hospital's risk-adjusted mortality rate was poorly associated with its future mortality. The annual hospital PCI-related mortality may not be a reliable factor associated with hospital quality to consider in a practice change or when helping patients select high-quality hospitals.
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Affiliation(s)
- Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Shun Kohsaka
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California.,Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Jay Bhattacharya
- Center for Health Policy, Department of Medicine, Stanford University, Stanford, California.,Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University, Stanford, California
| | - William F Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Robert A Harrington
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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Affiliation(s)
- Frederic S Resnic
- Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, MA (F.S.R.)
| | - Arjun Majithia
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (A.M.)
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