ABSTRACT
OBJECTIVE: Contrast-sparing strategies have been developed for percutaneous coronary intervention (PCI) patients at increased risk of contrast-induced acute kidney injury (CI-AKI), and numerous CI-AKI risk prediction models have been created. However, the potential clinical and economic consequences of using predicted CI-AKI risk thresholds for assigning patients to contrast-sparing regimens have not been evaluated. We estimated the clinical and economic consequences of alternative CI-AKI risk thresholds for assigning Medicare PCI patients to contrast-sparing strategies. METHODS: Medicare data were used to identify inpatient PCI from January 2017 to June 2021. A prediction model was developed to assign each patient a predicted probability of CI-AKI. Multivariable modeling was used to assign each patient two marginal predicted values for each of several clinical and economic outcomes based on (1) their underlying clinical and procedural characteristics plus their true CI-AKI status in the data and (2) their characteristics plus their counterfactual CI-AKI status. Specifically, CI-AKI patients above the predicted risk threshold for contrast-sparing were reassigned their no CI-AKI (counterfactual) outcomes. Expected event rates, resource use, and costs were estimated before and after those CI-AKI patients were reassigned their counterfactual outcomes. This entailed bootstrapped sampling of the full cohort. RESULTS: Of the 542,813 patients in the study cohort, 5,802 (1.1%) had CI-AKI. The area under the receiver operating characteristic curve for the prediction model was 0.81. At a predicted risk threshold for CI-AKI of >2%, approximately 18.0% of PCI patients were assigned to contrast-sparing strategies, resulting in (/100,000 PCI patients) 121 fewer deaths, 58 fewer myocardial infarction readmissions, 4,303 fewer PCI hospital days, $11.3 million PCI cost savings, and $25.8 million total one-year cost savings, versus no contrast-sparing strategies. LIMITATIONS: Claims data may not fully capture disease burden and are subject to inherent limitations such as coding inaccuracies. Further, the dataset used reflects only individuals with fee-for-service Medicare, and the results may not be generalizable to Medicare Advantage or other patient populations. CONCLUSIONS: Assignment to contrast-sparing regimens at a predicted risk threshold close to the underlying incidence of CI-AKI is projected to result in significant clinical and economic benefits.
Subject(s)
Acute Kidney Injury , Contrast Media , Medicare , Percutaneous Coronary Intervention , Humans , Percutaneous Coronary Intervention/methods , Percutaneous Coronary Intervention/economics , Percutaneous Coronary Intervention/adverse effects , Acute Kidney Injury/chemically induced , Contrast Media/adverse effects , United States , Male , Female , Aged , Risk Assessment , Aged, 80 and over , Risk FactorsABSTRACT
BACKGROUND: The American College of Cardiology Reduce the Risk: PCI Bleed Campaign was a hospital-based quality improvement campaign designed to reduce post-percutaneous coronary intervention (PCI) bleeding events. The aim of the campaign was to provide actionable evidence-based tools for participants to review, adapt, and adopt, depending upon hospital resources and engagement. METHODS: We used data from 8â 757â 737 procedures in the National Cardiovascular Data Registry between 2015 and 2021 to compare patient and hospital characteristics and bleeding outcomes among campaign participants (n=195 hospitals) and noncampaign participants (n=1384). Post-PCI bleeding risk was compared before and after campaign participation. Multivariable hierarchical logistic regression was used to determine the adjusted association between campaign participation and post-PCI bleeding events. Prespecified subgroups were examined. RESULTS: Campaign hospitals were more often higher volume teaching facilities located in urban or suburban locations. After adjustment, campaign participation was associated with a significant reduction in the rate of bleeding (bleeding: adjusted odds ratio, 0.61 [95% CI, 0.53-0.71]). Campaign hospitals had a greater decrease in bleeding events than noncampaign hospitals. In a subgroup analysis, the reduction in bleeding was noted in non-ST-segment-elevation acute coronary syndrome and ST-segment-elevation myocardial infarction patients, but no significant reduction was seen in patients without acute coronary syndrome. CONCLUSIONS: Participation in the American College of Cardiology Reduce the Risk: PCI Bleed Campaign was associated with a significant reduction in post-PCI bleeding. Our results underscore that national quality improvement efforts can be associated with a significant impact on PCI outcomes.
Subject(s)
Acute Coronary Syndrome , Percutaneous Coronary Intervention , Humans , Acute Coronary Syndrome/diagnostic imaging , Acute Coronary Syndrome/therapy , Hemorrhage/etiology , Hemorrhage/prevention & control , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/methods , Registries , Risk Factors , Treatment Outcome , United StatesABSTRACT
BACKGROUND: Acute kidney injury (AKI) is the most common complication after percutaneous coronary intervention (PCI). Accurately estimating patients' risks not only creates a means of benchmarking performance but can also be used prospectively to inform practice. OBJECTIVES: The authors sought to update the 2014 National Cardiovascular Data Registry (NCDR) AKI risk model to provide contemporary estimates of AKI risk after PCI to further improve care. METHODS: Using the NCDR CathPCI Registry, we identified all 2020 PCIs, excluding those on dialysis or lacking postprocedural creatinine. The cohort was randomly split into a 70% derivation cohort and a 30% validation cohort, and logistic regression models were built to predict AKI (an absolute increase of 0.3 mg/dL in creatinine or a 50% increase from preprocedure baseline) and AKI requiring dialysis. Bedside risk scores were created to facilitate prospective use in clinical care, along with threshold contrast doses to reduce AKI. We tested model calibration and discrimination in the validation cohort. RESULTS: Among 455,806 PCI procedures, the median age was 67 years (IQR: 58.0-75.0 years), 68.8% were men, and 86.8% were White. The incidence of AKI and new dialysis was 7.2% and 0.7%, respectively. Baseline renal function and variables associated with clinical instability were the strongest predictors of AKI. The final AKI model included 13 variables, with a C-statistic of 0.798 and excellent calibration (intercept = -0.03 and slope = 0.97) in the validation cohort. CONCLUSIONS: The updated NCDR AKI risk model further refines AKI prediction after PCI, facilitating enhanced clinical care, benchmarking, and quality improvement.
Subject(s)
Acute Kidney Injury , Percutaneous Coronary Intervention , Male , Humans , Aged , Female , Risk Assessment , Percutaneous Coronary Intervention/adverse effects , Creatinine , Treatment Outcome , Risk Factors , Acute Kidney Injury/diagnosis , Acute Kidney Injury/epidemiology , Acute Kidney Injury/therapy , Contrast Media/adverse effectsABSTRACT
BACKGROUND: The prediction of mortality, bleeding, and acute kidney injury (AKI) after percutaneous coronary intervention (PCI) traditionally relied on race-based estimates of the glomerular filtration rate (GFR). Recently, race agnostic equations were developed to advance equity. OBJECTIVES: The authors aimed to compare the accuracy and implications of various GFR equations when used to predict AKI after PCI. METHODS: Using the National Cardiovascular Data Registry (NCDR) CathPCI data set, we identified patients undergoing PCI in 2020 and calculated their AKI risk using the 2014 NCDR AKI risk model. We created 4 AKI models per patient for each estimate of baseline renal function: the traditional GFR equation with a race term, 2 GFR equations without a race term, and serum creatinine alone. We then compared each model's performance predicting AKI. RESULTS: Among 455,806 PCI encounters, the median age was 67 years, 32.2% were women, and 8.5% were Black. In Black patients, risk models without a race term were better calibrated than models incorporating an equation with a race term (intercept: -0.01 vs 0.15). Race-agnostic models reclassified 6% of Black patients into higher-risk categories, potentially prompting appropriate mitigation efforts. However, even with a race-agnostic model, AKI occurred in Black patients 18% more often than expected, which was not explained by captured patient or procedural characteristics. CONCLUSIONS: Incorporating a GFR estimate without a Black race term into the NCDR AKI risk prediction model yielded more accurate prediction of AKI risk for Black patients, which has important implications for reducing disparities and benchmarking.
Subject(s)
Acute Kidney Injury , Percutaneous Coronary Intervention , Humans , Female , Aged , Male , Risk Assessment , Risk Factors , Percutaneous Coronary Intervention/adverse effects , Glomerular Filtration Rate , Treatment Outcome , Acute Kidney Injury/diagnosis , Acute Kidney Injury/therapy , CreatinineABSTRACT
BACKGROUND: Acute kidney injury (AKI), including contrast-induced AKI (CI-AKI), is an important complication of percutaneous coronary intervention (PCI), resulting in short- and long-term adverse clinical outcomes. While prior research has reported an increased cost burden to hospitals from CI-AKI, the incremental cost to payers remains unknown. Understanding this incremental cost may inform decisions and even policy in the future. The objective of this study was to estimate the short- and long-term cost to Medicare of AKI overall, and specifically CI-AKI, in PCI. METHODS: Patients undergoing inpatient PCI between January 2017 and June 2020 were selected from Medicare 100% fee-for-service data. Baseline clinical characteristics, PCI lesion/procedural characteristics, and AKI/CI-AKI during the PCI admission, were identified from diagnosis and procedure codes. Poisson regression, generalized linear modelling, and longitudinal mixed effects modelling, in full and propensity-matched cohorts, were used to compare PCI admission length of stay (LOS) and cost (Medicare paid amount inflated to 2022 US$), as well as total costs during 1-year following PCI, between AKI and non-AKI patients. RESULTS: The study cohort included 509,039 patients, of whom 104,033 (20.4%) were diagnosed with AKI and 9,691 (1.9%) with CI-AKI. In the full cohort, AKI was associated with +4.12 (95% confidence interval = 4.10, 4.15) days index PCI admission LOS, +$11,313 ($11,093, $11,534) index admission costs, and +$14,800 ($14,359, $15,241) total 1-year costs. CI-AKI was associated with +3.03 (2.97, 3.08) days LOS, +$6,566 ($6,148, $6,984) index admission costs, and +$13,381 ($12,118, $14,644) cumulative 1-year costs (all results are adjusted for baseline characteristics). Results from the propensity-matched analyses were similar. CONCLUSIONS: AKI, and specifically CI-AKI, during PCI is associated with significantly longer PCI admission LOS, PCI admission costs, and long-terms costs.
Subject(s)
Acute Kidney Injury , Percutaneous Coronary Intervention , Humans , Aged , United States/epidemiology , Percutaneous Coronary Intervention/methods , Risk Factors , Medicare , Forecasting , Acute Kidney Injury/chemically induced , Acute Kidney Injury/epidemiology , Contrast Media/adverse effectsABSTRACT
In the United States, the frequency of using percutaneous mechanical circulatory support devices for acute myocardial infarction complicated by cardiogenic shock is increasing. These devices require large-bore vascular access to provide left, right, or biventricular cardiac support, frequently under urgent/emergent circumstances. Significant technical and logistical variability exists in device insertion, care, and removal in the cardiac catheterization laboratory and in the cardiac intensive care unit. This variability in practice may contribute to adverse outcomes observed in centers that receive patients with cardiogenic shock, who are at higher risk for circulatory insufficiency, venous stasis, bleeding, and arterial hypoperfusion. In this position statement, we aim to: 1) describe the public health impact of bleeding and vascular complications in cardiogenic shock; 2) highlight knowledge gaps for vascular safety and provide a roadmap for a regulatory perspective necessary for advancing the field; 3) propose a minimum core set of process elements, or "vascular safety bundle"; and 4) develop a possible study design for a pragmatic trial platform to evaluate which structured approach to vascular access drives most benefit and prevents vascular and bleeding complications in practice.
Subject(s)
Heart-Assist Devices , Myocardial Infarction , Humans , United States , Shock, Cardiogenic/diagnosis , Shock, Cardiogenic/etiology , Shock, Cardiogenic/therapy , Heart-Assist Devices/adverse effects , Treatment Outcome , Myocardial Infarction/complications , Myocardial Infarction/therapy , Hemorrhage/etiology , Hemorrhage/prevention & controlABSTRACT
OBJECTIVE: We examined the association of iso-osmolar contrast media (IOCM) versus low-osmolar contrast media (LOCM) with major adverse renal, cardiovascular, or limb events in patients at high-risk of acute kidney injury (AKI) undergoing peripheral endovascular procedures. BACKGROUND: Procedural characteristics including iodinated contrast type and volume have been associated with adverse renal and cardiovascular outcomes in patients undergoing angiographic interventions. METHODS: Patients at high-risk of AKI, undergoing peripheral endovascular procedures were identified using the Premier Healthcare Database and separated into claudication and critical limb ischemia (CLI) cohorts. For each cohort, we compared IOCM versus LOCM for the primary endpoint of MARCE (major adverse renal or cardiovascular events) and secondary endpoints of major adverse renal events (MARE) and major adverse renal and limb events (MARLE). These outcomes were captured within the indexed hospitalization via adjusted multivariable regression analyses. RESULTS: Two procedure-based cohorts of high-risk patients were formed: claudication (N = 11,976) and CLI (N = 8713). Use of IOCM was associated with a significant absolute risk reduction (ARR) of 2.2% (p < 0.0001) for MARCE overall and in each cohort (claudication, 1.8%, p = 0.0070; CLI, 2.7%, p = 0.0054). The incidence of MARE and MARLE in the overall cohort was also lower with the use of IOCM: MARE (ARR = 1.4%, p = 0.0072) and MARLE (ARR = 2.0%, p = 0.0043). CONCLUSIONS: Using IOCM versus LOCM in patients at high-risk of adverse renal events undergoing peripheral endovascular procedures was independently associated with lower risk of MARCE, MARE, and MARLE.
Subject(s)
Acute Kidney Injury , Endovascular Procedures , Peripheral Arterial Disease , Acute Kidney Injury/chemically induced , Acute Kidney Injury/diagnosis , Acute Kidney Injury/epidemiology , Contrast Media/adverse effects , Endovascular Procedures/adverse effects , Female , Humans , Incidence , Ischemia/diagnostic imaging , Ischemia/epidemiology , Ischemia/therapy , Male , Osmolar Concentration , Peripheral Arterial Disease/diagnostic imaging , Peripheral Arterial Disease/therapy , Risk Factors , Treatment OutcomeABSTRACT
BACKGROUND: Bleeding is a common and costly complication of percutaneous coronary intervention (PCI). Bleeding avoidance strategies (BAS) are used paradoxically less in patients at high-risk of bleeding: "bleeding risk-treatment paradox" (RTP). We determined whether hospitals and physicians, who do not align BAS to PCI patients' bleeding risk (ie, exhibit a RTP) have higher bleeding rates. METHODS: We examined 28,005 PCIs from the National Cardiovascular Data Registry CathPCI Registry for 7 hospitals comprising BJC HealthCare. BAS included transradial intervention, bivalirudin, and vascular closure devices. Patients' predicted bleeding risk was based on National Cardiovascular Data Registry CathPCI bleeding model and categorized as low (<2.0%), moderate (2.0%-6.4%), or high (≥6.5%) risk tertiles. BAS use was considered risk-concordant if: at least 1 BAS was used for moderate risk; 2 BAS were used for high risk and bivalirudin or vascular closure devices were not used for low risk. Absence of risk-concordant BAS use was defined as RTP. We analyzed inter-hospital and inter-physician variation in RTP, and the association of RTP with post-PCI bleeding. RESULTS: Amongst 28,005 patients undergoing PCI by 103 physicians at 7 hospitals, RTP was observed in 12,035 (43%) patients. RTP was independently associated with a higher likelihood of bleeding even after adjusting for predicted bleeding risk, mortality risk and potential sources of variation (OR 1.66, 95% CI 1.44-1.92, P < .001). A higher prevalence of RTP strongly and independently correlated with worse bleeding rates, both at the physician-level (Wilk's Lambda 0.9502, F-value 17.21, P < .0001) and the hospital-level (Wilk's Lambda 0.9899, F-value 35.68, P < .0001). All the results were similar in a subset of PCIs conducted since 2015 - a period more reflective of the contemporary practice. CONCLUSIONS: Bleeding RTP is a strong, independent predictor of bleeding. It exists at the level of physicians and hospitals: those with a higher rate of RTP had worse bleeding rates. These findings not only underscore the importance of recognizing bleeding risk upfront and using BAS in a risk-aligned manner, but also inform and motivate national efforts to reduce PCI-related bleeding.
Subject(s)
Percutaneous Coronary Intervention , Physicians , Hemorrhage/epidemiology , Hemorrhage/etiology , Hemorrhage/prevention & control , Hospitals , Humans , Percutaneous Coronary Intervention/adverse effects , Registries , Risk Factors , Treatment OutcomeABSTRACT
Patients with chronic kidney disease (CKD) are at an increased risk of developing cardiovascular disease (CVD), whereas those with established CVD are at risk of incident or progressive CKD. Compared with individuals with normal or near normal kidney function, there are fewer data to guide the management of patients with CVD and CKD. As a joint effort between the National Kidney Foundation and the Society for Cardiovascular Angiography and Interventions, a workshop and subsequent review of the published literature was held. The present document summarizes the best practice recommendations of the working group and highlights areas for further investigation.
ABSTRACT
â¢Single radial artery access for direct transmitral gradient measurement is feasibleâ¢A radial TIG coronary catheter can be advanced retrograde into the left atriumâ¢A coronary pressure wire is delivered to the left atrium and left in placeâ¢The catheter is subsequently withdrawn into the left ventricleâ¢This permits simultaneous left atrial and left ventricular hemodynamic assessment.
ABSTRACT
OBJECTIVES: The aims of this study were to describe trends and hospital variation in same-day discharge following elective percutaneous coronary intervention (PCI) and to evaluate the association between trends in same-day discharge and patient outcomes. BACKGROUND: Insights on contemporary use of same-day discharge following elective PCI are limited. METHODS: In a sequential cross-sectional analysis of 819,091 patients undergoing elective PCI at 1,716 hospitals in the National Cardiovascular Data Registry CathPCI Registry from July 1, 2009, to December 31, 2017, overall and hospital-level trends in same-day discharge were assessed. Among the 212,369 patients who linked to Centers for Medicare and Medicaid Services data, the association between same-day discharge and 30-day mortality and rehospitalization was assessed. RESULTS: A total of 114,461 patients (14.0%) were discharged the same day as PCI. The proportion of patients with same-day discharge increased from 4.5% in the third quarter of 2009 to 28.6% in the fourth quarter of 2017. From 2009 to 2017, the rate of same-day discharge increased from 4.3% to 19.5% for femoral-access PCI and from 9.9% to 39.7% for radial-access PCI. Hospital-level variation in the use of same-day discharge persisted throughout (median odds ratio adjusted for year and radial access: 4.15). Risk-adjusted 30-day mortality did not change over time, while risk-adjusted rehospitalization decreased over time and more quickly for same-day discharge (P for interaction <0.001). CONCLUSIONS: In the past decade, a large increase in the use of same-day discharge following elective PCI was not associated with worse 30-day mortality or rehospitalization. Hospital-level variation in same-day discharge may represent an opportunity to reduce costs without compromising patient outcomes.
Subject(s)
Coronary Artery Disease , Percutaneous Coronary Intervention , Aged , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/surgery , Cross-Sectional Studies , Humans , Length of Stay , Medicare , Patient Discharge , Percutaneous Coronary Intervention/adverse effects , Registries , Treatment Outcome , United States/epidemiologyABSTRACT
OBJECTIVE: The purpose of this analysis was to examine the association of iso-osmolar contrast media (IOCM) vs low-osmolar contrast media (LOCM) with major adverse renal or cardiovascular events (MARCE) in patients at high risk of acute kidney injury (AKI), undergoing endovascular abdominal aortic aneurysm repair (EVAR). METHODS: Patients at high risk of AKI (defined as age ≥75 years, or one or more of the following comorbidities: diabetes, anemia, chronic kidney disease (CKD stages 1-4) or congestive heart failure), undergoing EVAR from September 2012 to June 2018 were identified using the Premier Hospital Database. We compared the primary endpoint of MARCE (composite of AKI, AKI requiring dialysis, acute myocardial infarction [AMI], stroke/transient ischemic attack [TIA], and death) with IOCM vs LOCM via adjusted multivariable regression analyses. RESULTS: Among 15,777 high-risk patients undergoing EVAR, the occurrence of in-hospital MARCE was 6.8%, including renal events (4.5%), AMI (0.8%), stroke/TIA (0.4%), and death (1.9%), IOCM was used in 7360 patients (47%). Multivariable modeling found IOCM was associated with 1.8% (95% confidence interval [CI], 0.4-3.3; P=.01) lower absolute risk for MARCE (23.9% relative risk reduction; 95% CI, 5.2%-44.2%). CONCLUSIONS: Use of IOCM vs LOCM in patients at high risk of AKI undergoing EVAR procedures was associated with a lower risk of MARCE. As prevention of AKI or cardiovascular events after EVAR procedures may lead to reduced morbidity and mortality, this finding may have important clinical implications and should be confirmed through randomized controlled clinical studies.
Subject(s)
Acute Kidney Injury , Aortic Aneurysm, Abdominal , Blood Vessel Prosthesis Implantation , Endovascular Procedures , Acute Kidney Injury/chemically induced , Acute Kidney Injury/diagnosis , Acute Kidney Injury/epidemiology , Aged , Aortic Aneurysm, Abdominal/surgery , Contrast Media/adverse effects , Endovascular Procedures/adverse effects , Humans , Kidney , Retrospective Studies , Risk Factors , Treatment Outcome , Vascular Surgical ProceduresABSTRACT
Transradial access for PCI (TRI) along with same day discharge (SDD) is associated with varying estimates of cost savings depending on the population studied, the clinical scenario and application to low-risk vs high-risk patients. A summary estimate of the true cost savings of TRI and SDD are unknown. We searched the PubMed, EMBASE®, CINAHL® and Google Scholar® databases for published studies on hospitalization costs of TRI and SDD. Primary outcome of interest in all included studies was the cost saving with TRI (or SDD), inflation-corrected US$ 2018 values using the medical consumer price index. For meta-analytic synthesis, we used Hedges' summary estimate (g) in a random-effects framework of the DerSimonian and Laird model, with inverse variance weights. Heterogeneity was quantified using the I2 statistic. The cost savings of TRI from four US studies of 349,757 patients reported a consistent and significant cost saving associated with TRI after accounting for currency inflation, of US$ 992 (95% CI US$ 850-1,134). The cost savings of SDD from six US studies of 1,281,228 patients, after inflation-correcting to the year 2018, were US$ 3,567.58 (95% CI US$ 2,303-4,832). In conclusion, this meta-analysis demonstrates that TRI and SDD are associated with mean cost reductions of by approximately US$ 1,000/patient and US$ 3,600/patient, respectively, albeit with wide heterogeneity in the cost estimates. When combined with the safety of TRI and SDD, this meta-analysis underscores the value of combining TRI and SDD pathways and calls for a wide-ranging practice change in the direction of TRI and SDD.
Subject(s)
Percutaneous Coronary Intervention , Cost Savings , Humans , Length of Stay , Patient Discharge , Percutaneous Coronary Intervention/adverse effects , Treatment OutcomeABSTRACT
[Figure: see text].
Subject(s)
Percutaneous Coronary Intervention , Radial Artery , Femoral Artery , Hemorrhage , Humans , Percutaneous Coronary Intervention/adverse effects , Radial Artery/diagnostic imaging , Risk Factors , Treatment OutcomeABSTRACT
Importance: Mechanical circulatory support (MCS) devices, including intravascular microaxial left ventricular assist devices (LVADs) and intra-aortic balloon pumps (IABPs), are used in patients who undergo percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) complicated by cardiogenic shock despite limited evidence of their clinical benefit. Objective: To examine trends in the use of MCS devices among patients who underwent PCI for AMI with cardiogenic shock, hospital-level use variation, and factors associated with use. Design, Setting, and Participants: This cross-sectional study used the CathPCI and Chest Pain-MI Registries of the American College of Cardiology National Cardiovascular Data Registry. Patients who underwent PCI for AMI complicated by cardiogenic shock between October 1, 2015, and December 31, 2017, were identified from both registries. Data were analyzed from October 2018 to August 2020. Exposures: Therapies to provide hemodynamic support were categorized as intravascular microaxial LVAD, IABP, TandemHeart, extracorporeal membrane oxygenation, LVAD, other devices, combined IABP and intravascular microaxial LVAD, combined IABP and other device (defined as TandemHeart, extracorporeal membrane oxygenation, LVAD, or another MCS device), or medical therapy only. Main Outcomes and Measures: Use of MCS devices overall and specific MCS devices, including intravascular microaxial LVAD, at both patient and hospital levels and variables associated with use. Results: Among the 28â¯304 patients included in the study, the mean (SD) age was 65.4 (12.6) years and 18 968 were men (67.0%). The overall MCS device use was constant from the fourth quarter of 2015 to the fourth quarter of 2017, although use of intravascular microaxial LVADs significantly increased (from 4.1% to 9.8%; P < .001), whereas use of IABPs significantly decreased (from 34.8% to 30.0%; P < .001). A significant hospital-level variation in MCS device use was found. The median (interquartile range [IQR]) proportion of patients who received MCS devices was 42% (30%-54%), and the median proportion of patients who received intravascular microaxial LVADs was 1% (0%-10%). In multivariable analyses, cardiac arrest at first medical contact or during hospitalization (odds ratio [OR], 1.82; 95% CI, 1.58-2.09) and severe left main and/or proximal left anterior descending coronary artery stenosis (OR, 1.36; 95% CI, 1.20-1.54) were patient characteristics that were associated with higher odds of receiving intravascular microaxial LVADs only compared with IABPs only. Conclusions and Relevance: This study found that, among patients who underwent PCI for AMI complicated by cardiogenic shock, overall use of MCS devices was constant, and a 2.5-fold increase in intravascular microaxial LVAD use was found along with a corresponding decrease in IABP use and a significant hospital-level variation in MCS device use. These trends were observed despite limited clinical trial evidence of improved outcomes associated with device use.
Subject(s)
Extracorporeal Membrane Oxygenation/trends , Heart-Assist Devices/trends , Intra-Aortic Balloon Pumping/trends , Myocardial Infarction/therapy , Percutaneous Coronary Intervention/methods , Shock, Cardiogenic/therapy , Aged , Assisted Circulation/trends , Cross-Sectional Studies , Female , Heart Arrest/epidemiology , Hospitals, High-Volume , Hospitals, Low-Volume , Hospitals, Teaching , Humans , Male , Middle Aged , Myocardial Infarction/complications , Risk Factors , Shock, Cardiogenic/etiologyABSTRACT
Despite decades of improvement in the quality and outcomes of cardiovascular care, significant gaps remain. Existing quality improvement strategies are often limited in scope to specific clinical conditions and episodic care. Health services and outcomes research is essential to inform gaps in care but rarely results in the development and implementation of care delivery solutions. Although individual health systems are engaged in projects to improve the quality of care delivery, these efforts often lack a robust study design or implementation evaluation that can inform generalizability and further dissemination. Aligning the work of health care systems and health services and outcomes researchers could serve as a strategy to overcome persisting gaps in cardiovascular quality and outcomes. We describe the inception of the Cardiovascular Quality Improvement and Care Innovation Consortium that seeks to rapidly improve cardiovascular care by (1) developing, implementing, and evaluating multicenter quality improvement projects using innovative care designs; (2) serving as a resource for quality improvement and care innovation partners; and (3) establishing a presence within existing quality improvement and care innovation structures. Success of the collaborative will be defined by projects that result in changes to care delivery with demonstrable impacts on the quality and outcomes of care across multiple health systems. Furthermore, insights gained from implementation of these projects across sites in Cardiovascular Quality Improvement and Care Innovation Consortium will inform and promote broad dissemination for greater impact.
Subject(s)
Delivery of Health Care , Quality Improvement , Humans , Research DesignABSTRACT
OBJECTIVES: This study aimed to examine the cost of coronary syndrome treated with percutaneous coronary intervention (PCI) and 30-day unplanned readmissions. BACKGROUND: There is limited understanding of the hospital cost of index PCI and 30-day unplanned readmissions. METHODS: Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were included. The primary outcome was total cost defined by cost of index PCI and first unplanned readmission within 30 days. RESULTS: This analysis included 2,294,244 patients who underwent PCI, and the mean cost was $23,541 ± $20,730 (~$10.8 billion/year). There was a modest increase in cost over the study years of 17.5%. Of the 9.4% with an unplanned readmission within 30 days, the mean total cost was $35,333 ± 24,230 versus $22,323 ± 19,941 for those not readmitted. The variables most strongly associated with the highest quartile of cost were heart failure (adjusted odds ratio (aOR) 25.60 [95% CI 21.59-30.35]), need for circulatory support (aOR 11.62 [10.13-13.32]), periprocedural coronary artery bypass graft (CABG, aOR 585.08 [357.85-956.58]), and readmission within 30 days (aOR 24.49 [22.40-26.77]). An acute kidney injury (AKI; 8.5%), major bleed (0.8%), vascular injury (0.8%), or need for periprodedural CABG (1.4%) had an average increased cost of $21,935; $30,898; $27,875; and $43,005, respectively, compared to PCI without adverse outcome. CONCLUSIONS: The annual 30-day hospital cost of PCI is approximately $10.8 billion, and the costs associated with in-hospital adverse events, particularly the need for AKI and periprocedural CABG, were significant.
Subject(s)
Patient Readmission , Percutaneous Coronary Intervention , Coronary Artery Bypass , Hospital Costs , Humans , Percutaneous Coronary Intervention/adverse effects , Treatment Outcome , United States/epidemiologyABSTRACT
BACKGROUND: Prolonged length of stay (LOS) and post-acute care after percutaneous coronary intervention (PCI) is common and costly. Risk models for predicting prolonged LOS and post-acute care have limited accuracy. Our goal was to develop and validate models using artificial neural networks (ANN) to predict prolonged LOS > 7days and need for post-acute care after PCI. METHODS: We defined prolonged LOS as ≥7 days and post-acute care as patients discharged to: extended care, transitional care unit, rehabilitation, other acute care hospital, nursing home or hospice care. Data from 22 675 patients who presented with ACS and underwent PCI was shuffled and split into a derivation set (75% of dataset) and a validation dataset (25% of dataset). Calibration plots were used to examine the overall predictive performance of the MLP by plotting observed and expected risk deciles and fitting a lowess smoother to the data. Classification accuracy was assessed by a receiver-operating characteristic (ROC) and area under the ROC curve (AUC). RESULTS: Our MLP-based model predicted prolonged LOS with an accuracy of 90.87% and 88.36% in training and test sets, respectively. The post-acute care model had an accuracy of 90.22% and 86.31% in training and test sets, respectively. This accuracy was achieved with quick convergence. Predicted probabilities from the MLP models showed good (prolonged LOS) to excellent calibration (post-acute care). CONCLUSIONS: Our ANN-based models accurately predicted LOS and need for post-acute care. Larger studies for replicability and longitudinal studies for evidence of impact are needed to establish these models in current PCI practice.
Subject(s)
Acute Coronary Syndrome/surgery , Length of Stay/statistics & numerical data , Neural Networks, Computer , Percutaneous Coronary Intervention , Subacute Care/statistics & numerical data , Aged , Angina, Unstable/surgery , Female , Hospices , Hospitals, Rehabilitation , Humans , Male , Middle Aged , Non-ST Elevated Myocardial Infarction/surgery , Nursing Homes , Patient Discharge , Risk Assessment , ST Elevation Myocardial Infarction/surgery , Skilled Nursing Facilities , Transitional CareABSTRACT
BACKGROUND: Temporary mechanical circulatory support (MCS) devices are increasingly used in cardiogenic shock, but whether sociodemographic differences by sex, race and/or ethnicity, insurance status, and neighborhood poverty exist in the utilization of these devices is unknown. METHODS: Retrospective cross-sectional study using the National Inpatient Sample for 2012-2017. Logistic regression models were used to examine predictors of use of temporary MCS devices and for in-hospital mortality, clustering by hospital-year. RESULTS: Our study population included 109,327 admissions for cardiogenic shock. Overall, 14.3% of admissions received an intra-aortic balloon pump, 4.2% a percutaneous ventricular assist device, and 1.8% extracorporeal membranous oxygenation (ECMO). After adjusting for age, comorbidities, and hospital characteristics, use of temporary MCS was lower in women compared to men (adjusted odds ratio [aOR]â¯=â¯0.76, P < .001), Black patients compared to white ones (aORâ¯=â¯0.73, P < .001), those insured by Medicare (aORâ¯=â¯0.75, P < .001), Medicaid (aORâ¯=â¯0.74, P < .001), or uninsured (aORâ¯=â¯0.90, Pâ¯=â¯.015) compared to privately insured, and those in the lowest income neighborhoods (aORâ¯=â¯0.94, Pâ¯=â¯.003) versus other neighborhoods. Women, admissions covered by Medicare, Medicaid, or uninsured, and those from low-income neighborhoods also had higher mortality rates even after adjustment for MCS implantation. CONCLUSIONS: There are differences in the use of temporary MCS in the setting of cardiogenic shock among specific populations within the United States. The growing use of MCS for treating cardiogenic shock highlights the need to better understand its impact on outcomes.