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1.
JAMA ; 2020 Feb 10.
Artigo em Inglês | MEDLINE | ID: mdl-32040163

RESUMO

Importance: Acute myocardial infarction (AMI) complicated by cardiogenic shock is associated with substantial morbidity and mortality. Although intravascular microaxial left ventricular assist devices (LVADs) provide greater hemodynamic support as compared with intra-aortic balloon pumps (IABPs), little is known about clinical outcomes associated with intravascular microaxial LVAD use in clinical practice. Objective: To examine outcomes among patients undergoing percutaneous coronary intervention (PCI) for AMI complicated by cardiogenic shock treated with mechanical circulatory support (MCS) devices. Design, Setting, and Participants: A propensity-matched registry-based retrospective cohort study of patients with AMI complicated by cardiogenic shock undergoing PCI between October 1, 2015, and December 31, 2017, who were included in data from hospitals participating in the CathPCI and the Chest Pain-MI registries, both part of the American College of Cardiology's National Cardiovascular Data Registry. Patients receiving an intravascular microaxial LVAD were matched with those receiving IABP on demographics, clinical history, presentation, infarct location, coronary anatomy, and clinical laboratory data, with final follow-up through December 31, 2017. Exposures: Hemodynamic support, categorized as intravascular microaxial LVAD use only, IABP only, other (such as use of a percutaneous extracorporeal ventricular assist system, extracorporeal membrane oxygenation, or a combination of MCS device use), or medical therapy only. Main Outcomes and Measures: The primary outcomes were in-hospital mortality and in-hospital major bleeding. Results: Among 28 304 patients undergoing PCI for AMI complicated by cardiogenic shock, the mean (SD) age was 65.0 (12.6) years, 67.0% were men, 81.3% had an ST-elevation myocardial infarction, and 43.3% had cardiac arrest. Over the study period among patients with AMI, an intravascular microaxial LVAD was used in 6.2% of patients, and IABP was used in 29.9%. Among 1680 propensity-matched pairs, there was a significantly higher risk of in-hospital death associated with use of an intravascular microaxial LVAD (45.0%) vs with an IABP (34.1% [absolute risk difference, 10.9 percentage points {95% CI, 7.6-14.2}; P < .001) and also higher risk of in-hospital major bleeding (intravascular microaxial LVAD [31.3%] vs IABP [16.0%]; absolute risk difference, 15.4 percentage points [95% CI, 12.5-18.2]; P < .001). These associations were consistent regardless of whether patients received a device before or after initiation of PCI. Conclusions and Relevance: Among patients undergoing PCI for AMI complicated by cardiogenic shock from 2015 to 2017, use of an intravascular microaxial LVAD compared with IABP was associated with higher adjusted risk of in-hospital death and major bleeding complications, although study interpretation is limited by the observational design. Further research may be needed to understand optimal device choice for these patients.

2.
Am J Cardiol ; 125(3): 354-361, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-31812224

RESUMO

Acute coronary syndrome (ACS) admissions are common and costly. The association between comprehensive ACS care pathways, outcomes, and costs are lacking. From 434,172 low-risk, uncomplicated ACS patients eligible for early discharge (STEMI 35%, UA/NSTEMI 65%) from the Premier database, we identified ACS care pathways, by stratifying low-risk, uncomplicated STEMI and UA/NSTEMI patients by access site for PCI (trans-radial intervention [TRI] vs transfemoral intervention [TFI]) and by length of stay (LOS). Associations with costs and outcomes (death, bleeding, acute kidney injury, and myocardial infarction at 1-year) were tested using hierarchical, mixed-effects regression, and projections of cost savings with change in care pathways were obtained using modeling. In low-risk uncomplicated STEMI patients, compared with TFI and LOS ≥3 days, a strategy of TRI with LOS <3 days and TFI with LOS <3 days were associated with cost savings of $6,206 and $4,802, respectively. Corresponding cost savings for UA/NSTEMI patients were $7,475 and $6,169, respectively. These care-pathways did not show an excess risk of adverse outcomes. We estimated that >$300 million could be saved if prevalence of the TRI with LOS <3 days and TFI with LOS <3 days strategies are modestly increased to 20% and 70%, respectively. In conclusion, we demonstrate the potential opportunity of cost savings by repositioning ACS care pathways in low-risk and uncomplicated ACS patients, toward transradial access and a shorter LOS without an increased risk of adverse outcomes.

3.
Circulation ; 141(4): 273-284, 2020 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-31735078

RESUMO

BACKGROUND: Impella was approved for mechanical circulatory support (MCS) in 2008, but large-scale, real-world data on its use are lacking. Our objective was to describe trends and variations in Impella use, clinical outcomes, and costs across US hospitals in patients undergoing percutaneous coronary intervention (PCI) treated with MCS (Impella or intra-aortic balloon pump). METHODS: From the Premier Healthcare Database, we analyzed 48 306 patients undergoing PCI with MCS at 432 hospitals between January 2004 and December 2016. Association analyses were performed at 3 levels: time period, hospital, and patient. Hierarchical models with propensity adjustment were used for association analyses. We examined trends and variations in the proportion of Impella use, and associated clinical outcomes (in-hospital mortality, bleeding requiring transfusion, acute kidney injury, stroke, length of stay, and hospital costs). RESULTS: Among patients undergoing PCI treated with MCS, 4782 (9.9%) received Impella; its use increased over time, reaching 31.9% of MCS in 2016. There was wide variation in Impella use across hospitals (>5-fold variation). Specifically, among patients receiving Impella, there was a wide variation in outcomes of bleeding (>2.5-fold variation), and death, acute kidney injury, and stroke (all ≈1.5-fold variation). Adverse outcomes and costs were higher in the Impella era (years 2008-2016) versus the pre-Impella era (years 2004-2007). Hospitals with higher Impella use had higher rates of adverse outcomes and costs. After adjustment for the propensity score, and accounting for clustering of patients by hospitals, Impella use was associated with death: odds ratio, 1.24 (95% CI, 1.13-1.36); bleeding: odds ratio, 1.10 (95% CI, 1.00-1.21); and stroke: odds ratio, 1.34 (95% CI, 1.18-1.53), although a similar, nonsignificant result was observed for acute kidney injury: odds ratio, 1.08 (95% CI, 1.00-1.17). CONCLUSIONS: Impella use is rapidly increasing among patients undergoing PCI treated with MCS, with marked variability in its use and associated outcomes. Although unmeasured confounding cannot be ruled out, when analyzed by time periods, or at the hospital level or the patient level, Impella use was associated with higher rates of adverse events and costs. More data are needed to define the appropriate role of MCS in patients undergoing PCI.

4.
Am J Cardiol ; 125(1): 29-33, 2020 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-31711633

RESUMO

Contrast-induced acute kidney injury (AKI) is a common and severe complication of percutaneous coronary intervention (PCI). Despite its substantial burden, contemporary data on the incremental costs of AKI are lacking. We designed this large, nationally representative study to examine: (1) the independent, incremental costs associated with AKI after PCI and (2) to identify the departmental components of cost contributing to the incremental costs associated with AKI. In this observational cross-sectional study from the Premier database, we analyzed 1,443,297 PCI patients at 518 US hospitals from 1/2006 to 12/2015. Incremental cost of AKI from a hospital perspective obtained by a microcosting approach, was estimated using mixed-effects, multivariable linear regression with hospitals as random effects. Costs were inflation-corrected to 2016 US$. AKI occurred in 82,683 (5.73%) of the PCI patients. Those with AKI had higher hospitalization cost than those without ($38,869, SD 42,583 vs $17,167 SD 13,994, p <0.001). After adjustment, the incremental cost associated with an AKI was $9,448 (95% confidence interval $9,338 to $9,558, p <0.001). AKI was also independently associated with an incremental length of stay of 3.6 days (p <0.001). Room and board costs were the largest driver of AKI costs ($4,841). Extrapolated to the United States, our findings imply an annual AKI cost burden of 411.3 million US$. In conclusion, in this national study of PCI patients, AKI was common and independently associated with ∼$10,000 incremental costs, implying a substantial burden of AKI costs in US hospitals. Successful efforts to prevent AKI in patients who underwent PCI could result in meaningful cost savings.

5.
Interv Cardiol Clin ; 9(1): 107-115, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31733737

RESUMO

This review summarizes the impact of transradial access for cardiac catheterization and percutaneous coronary intervention related to patient satisfaction, patient safety, and health care costs. In studies comparing transradial versus transfemoral approach, transradial access causes less bleeding and less vascular access site complications and provides a mortality benefit in patients with acute coronary syndromes. Transradial access improves patient satisfaction related to site tolerability by reducing pain and discomfort, and facilitating early ambulation with reduced length of stay. Taken in total, the existing randomized and observational data strongly support radial access for improved safety, patient satisfaction, and significant cost savings.

6.
Artigo em Inglês | MEDLINE | ID: mdl-31876371

RESUMO

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.

8.
Eur Heart J Qual Care Clin Outcomes ; 5(4): 370-379, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-30895291

RESUMO

AIMS: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been shown to reduce angina and improve quality of life, but the frequency of new or residual angina after CTO PCI and its relationship with titration of anti-anginal medications (AAMs) has not been described. METHODS AND RESULTS: Among consecutive CTO PCI patients treated at 12 US centres in the OPEN CTO registry, angina was assessed 6 months after the index PCI using the Seattle Angina Questionnaire (SAQ) Angina Frequency scale (a score <100 defined new or residual angina). We then compared the proportion of patients with AAM escalation (defined as an increase in the number or dosage of AAMs between discharge and follow-up) between those with and without 6-month angina. Of 901 patients who underwent CTO PCI, 197 (21.9%) reported angina at 6-months, of whom 80 (40.6%) had de-escalation, 66 (33.5%) had no change, and only 51 (25.9%) had escalation of their AAM by the 6-month follow-up. Rates of AAM escalation were similar when stratifying patients by the ultimate success of the CTO PCI, completeness of physiologic revascularization, presence or absence of angina at baseline, history of heart failure, and by degree of symptomatic improvement after CTO PCI. CONCLUSIONS: One in five patients reported angina 6 months after CTO PCI. Although patients with new or residual angina were more likely to have escalation of AAMs in follow-up compared with those without residual symptoms, only one in four patients with residual angina had escalation of AAMs. Although it is unclear whether this finding reflects maximal tolerated therapy at baseline or therapeutic inertia, these findings suggest an important potential opportunity to further improve symptom control in patients with complex stable ischaemic heart disease.

10.
Catheter Cardiovasc Interv ; 93(7): 1228-1235, 2019 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-30393942

RESUMO

OBJECTIVE: To evaluate contrast media (CM) volume (CMV) saved using the DyeVert™ Plus Contrast Reduction System (DyeVert Plus System, Osprey Medical) in patients undergoing diagnostic coronary angiogram (CAG) and/or percutaneous coronary interventional (PCI) procedures performed with manual injections. BACKGROUND: Current guidelines advocate for monitoring and minimization of the total volume of CM in chronic kidney disease (CKD) patients undergoing invasive cardiac procedures. The DyeVert Plus System is an FDA cleared device designed to reduce CMV delivered during angiography and permit real-time CMV monitoring. METHODS: We performed a multicenter, single-arm, observational study. Eligible subjects were ≥ 18 years old with baseline estimated glomerular filtration rate (eGFR) 20-60 mL/min/1.73 m2 . The primary endpoint was % CMV saved over the total procedure. A secondary objective was to evaluate adverse events (AEs) related to DyeVert Plus System or to CM use. RESULTS: A total of 114 subjects were enrolled at eight centers. Mean age was 72 ± 9 years, 72% were male, and mean body mass index was 29 ± 5. Baseline eGFR was 43 ± 11 mL/min/1.73 m2 . CAG-only was performed in 65% of cases. One hundred and five subjects were evaluable for the primary endpoint. Mean CMV attempted was 112 ± 85 mL (range 22-681) and mean CMV delivered was 67 ± 51 mL (range 12-403), resulting in an overall CMV savings of 40.1 ± 8.8% (95% CI 38.4, 41.8; P < 0.0001) per procedure. Image quality was maintained in all but one case where the system was turned off for one injection. No DyeVert Plus System-related AEs were reported. Acute kidney injury (AKI; defined as serum creatinine rise of >0.3 mg/dL from baseline) was reported in 11 cases with seven occurring in subjects with baseline eGFR < 30 and three AKI events were attributed to CM. AKI rates increased as CMV/eGFR ratios increased. CONCLUSIONS: These data suggest DyeVert Plus System use in CKD patients undergoing CAG and/or PCI results in clinically meaningful CMV savings while maintaining image quality.

11.
J Am Heart Assoc ; 7(21): e008551, 2018 11 06.
Artigo em Inglês | MEDLINE | ID: mdl-30376760

RESUMO

Background Bleeding is a common, morbid, and costly complication of percutaneous coronary intervention. While bleeding avoidance strategies ( BAS ) are effective, they are used paradoxically less in patients at high risk of bleeding. Whether a patient-centered approach to specifically increase the risk-concordant use of BAS and, thus, reverse the risk-treatment paradox is associated with reduced bleeding and costs is unknown. Methods and Results We implemented an intervention to reverse the bleeding risk-treatment paradox at Barnes-Jewish Hospital, St. Louis, MO, and examined: (1) the temporal trends in BAS use and (2) the association of risk-concordant BAS use with bleeding and hospital costs of percutaneous coronary intervention. Among 3519 percutaneous coronary interventions, there was a significantly increasing trend ( P=0.002) in risk-concordant use of BAS . The bleeding incidence was 2% in the risk-concordant group versus 9% in the risk-discordant group (absolute risk difference, 7%; number needed to treat, 14). Risk-concordant BAS use was associated with a 67% (95% confidence interval, 52-78%; P<0.001) reduction in the risk of bleeding and a $4738 (95% confidence interval, 3353-6122; P<0.001) reduction in per-patient percutaneous coronary intervention hospitalization costs (21.6% cost-savings). Conclusions In this study, patient-centered care directly aimed to make treatment-related decisions based on predicted risk of bleeding, led to more risk-concordant use of BAS and reversal of the risk-treatment paradox. This, in turn, was associated with a reduction in bleeding and hospitalization costs. Larger multicentered studies are needed to corroborate these results. As clinical medicine moves toward personalization, both patients and hospitals can benefit from a simple practice change that encourages objectivity and mitigates variability in care.


Assuntos
Custos Hospitalares , Intervenção Coronária Percutânea , Hemorragia Pós-Operatória/economia , Hemorragia Pós-Operatória/prevenção & controle , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/epidemiologia , Estudos Prospectivos , Fatores de Risco
12.
Circ Cardiovasc Qual Outcomes ; 11(9): e004635, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30354547

RESUMO

Background To improve value in the care of patients with acute myocardial infarction (MI), payment models increasingly hold providers accountable for costs. As such, providers need tools to predict length of stay (LOS) during hospitalization and the likelihood of needing postacute care facilities after discharge for acute MI patients. We developed models to estimate risk for prolonged LOS and postacute care for acute MI patients at time of hospital admission to facilitate coordinated care planning. Methods and Results We identified patients in the National Cardiovascular Data Registry ACTION registry (Acute Coronary Treatment and Intervention Outcomes Network) who were discharged alive after hospitalization for acute MI between July 1, 2008 and March 31, 2017. Within a 70% random sample (Training cohort) we developed hierarchical, proportional odds models to predict LOS and hierarchical logistic regression models to predict discharge to postacute care. Models were validated in the remaining 30%. Of 633 737 patients in the Training cohort, 16.8% had a prolonged LOS (≥7 days) and 7.8% were discharged to a postacute facility (extended care, a transitional care unit, or rehabilitation). Model discrimination was moderate in the validation dataset for predicting LOS (C statistic=0.640) and strong for predicting discharge to postacute care (C statistic=0.827). For both models, discrimination was similar in ST-segment-elevation MI and non-ST-segment-elevation MI subgroups and calibration was excellent. Conclusions These models developed in a national registry can be used at the time of initial hospitalization to predict LOS and discharge to postacute facilities. Prospective testing of these models is needed to establish how they can improve care coordination and lower costs.


Assuntos
Técnicas de Apoio para a Decisão , Prestação Integrada de Cuidados de Saúde/organização & administração , Eficiência Organizacional , Tempo de Internação , Infarto do Miocárdio/terapia , Alta do Paciente , Melhoria de Qualidade/organização & administração , Indicadores de Qualidade em Assistência à Saúde/organização & administração , Cuidados Semi-Intensivos/organização & administração , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Prestação Integrada de Cuidados de Saúde/normas , Eficiência Organizacional/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/fisiopatologia , Alta do Paciente/normas , Valor Preditivo dos Testes , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Sistema de Registros , Fatores de Risco , Cuidados Semi-Intensivos/normas , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
13.
Circ Cardiovasc Qual Outcomes ; 11(10): e004788, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30354578

RESUMO

BACKGROUND: Readmissions within 30 days after acute myocardial infarction have been used as a performance metric for hospitals. However, evolving concepts of value-based reimbursement have shifted the focus to 90 days after hospital discharge. Tools are needed to determine risk for 90-day readmission to identify patients who might benefit from enhanced transitional healthcare resources. METHODS AND RESULTS: In this cohort study, we identified all Medicare beneficiaries with a primary diagnosis of acute myocardial infarction who were discharged from hospitals participating in National Cardiovascular Data Registry ACTION registry between 2008 and 2014. Among a random 70% sample (derivation cohort), we performed hierarchical proportional hazards regression, accounting for death as a competing risk, to assess predictors of all-cause readmission within 90 days. Models were validated in the remaining 30%. Among 86 849 unique patients, 23 912 (27.5%) were readmitted within 90 days. Of the readmissions, 55% occurred within 30 days and 81% occurred within 60 days. Predictors of readmission included older age and a history of diabetes mellitus or heart failure. Coronary revascularization was associated with a lower risk of readmission. A simple risk score incorporating patient demographic and clinical characteristics known before discharge identified groups of patients with readmission risks ranging from 13.1% to 42.9%. Model discrimination was moderate (C statistic=0.662), and calibration was excellent (slope=0.97, intercept=-0.04). CONCLUSIONS: Readmission within 90 days of hospitalization for acute myocardial infarction can be predicted by variables known before discharge and offers the potential to prospectively design transitional care to the risks of individual patients.


Assuntos
Técnicas de Apoio para a Decisão , Infarto do Miocárdio/terapia , Readmissão do Paciente , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Humanos , Masculino , Medicare , Infarto do Miocárdio/diagnóstico , Valor Preditivo dos Testes , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Cuidado Transicional , Resultado do Tratamento , Estados Unidos
14.
JAMA Cardiol ; 3(11): 1041-1049, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-30267035

RESUMO

Importance: Same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is associated with lower costs and preferred by patients. However, to our knowledge, contemporary patterns of SDD after elective PCI with respect to the incidence, hospital variation, trends, costs, and safety outcomes in the United States are unknown. Objective: To examine (1) the incidence and trends in SDD; (2) hospital variation in SDD; (3) the association between SDD and readmissions for bleeding, acute kidney injury (AKI), acute myocardial infarction (AMI), or mortality at 30, 90, and 365 days after PCI; and (4) hospital costs of SDD and its drivers. Design, Setting, and Participants: This observational cross-sectional cohort study included 672 470 patients enrolled in the nationally representative Premier Healthcare Database who underwent elective PCI from 493 hospitals between January 2006 and December 2015 with 1-year follow-up. Exposures: Same-day discharge, defined by identical dates of admission, PCI procedure, and discharge. Main Outcomes and Measures: Death, bleeding requiring a blood transfusion, AKI and AMI at 30, 90, or 365 days after PCI, and costs from hospitals' perspective, inflated to 2016. Results: Among 672 470 elective PCIs, 221 997 patients (33.0%) were women, 30 711 (4.6%) were Hispanic, 51 961 (7.7%) were African American, and 491 823 (73.1%) were white. The adjusted rate of SDD was 3.5% (95% CI, 3.0%-4.0%), which increased from 0.4% in 2006 to 6.3% in 2015. We observed substantial hospital variation for SDD from 0% to 83% (median incidence rate ratio, 3.82; 95% CI, 3.48-4.23), implying an average (median) 382% likelihood of SDD at one vs another hospital. Among SDD (vs non-SDD) patients, there was no higher risk of death, bleeding, AKI, or AMI at 30, 90, or 365 days. Same-day discharge was associated with a large cost savings of $5128 per procedure (95% CI, $5006-$5248), driven by reduced supply and room and boarding costs. A shift from existing SDD practices to match top-decile SDD hospitals could annually save $129 million in this sample and $577 million if adopted throughout the United States. However, residual confounding may be present, limiting the precision of the cost estimates. Conclusions and Relevance: Over 2006 to 2015, SDD after elective PCI was infrequent, with substantial hospital variation. Given the safety and large savings of more than $5000 per PCI associated with SDD, greater and more consistent use of SDD could markedly increase the overall value of PCI care.


Assuntos
Redução de Custos/métodos , Procedimentos Cirúrgicos Eletivos/economia , Intervenção Coronária Percutânea/economia , Idoso , Estudos Transversais , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Incidência , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos
15.
Catheter Cardiovasc Interv ; 92(5): E348-E355, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-29726596

RESUMO

BACKGROUND: Despite improvements in percutaneous coronary intervention (PCI), intraprocedural thrombotic events (IPTE) and bleeding complications occur and are prognostically important. These have not been included in prior economic studies. METHODS: PHOENIX ECONOMICS was a substudy of the CHAMPION PHOENIX trial, evaluating cangrelor during PCI. Hospital bills were reviewed from 1,171 patients enrolled at 22 of 63 US sites. Costs were estimated using standard methods including resource-based accounting, hospital billing data, and the Medicare fee schedule. Bleeding and IPTE, defined as abrupt vessel closure (transient or sustained), new/suspected thrombus, new clot on wire/catheter, no reflow, side-branch occlusion, procedural stent thrombosis or urgent need for CABG were identified. Costs were calculated according to whether a complication occurred and type of event. Multivariate analyses were used to estimate the incremental costs of IPTE and postprocedural events. RESULTS: IPTE occurred in 4.3% and were associated with higher catheterization laboratory and overall index hospitalization costs by $2,734 (95%CI $1,117, $4,351; P = 0.001) and $6,354 (95% CI $4,122, $8,586; P < 0.001), respectively. IPTE were associated with MI (35.4% vs. 3.6%; P < 0.001), out-of-laboratory stent thrombosis (4.2% vs. 0.1%; 0 = 0.005), ischemia driven revascularization (12.5% vs. 0.3%; P < 0.001), but not mortality (2.1% vs. 0.2%; P = 0.12) vs. no procedural thrombotic complication. By comparison, ACUITY minor bleeding increased hospitalization cost by $1,416 (95%CI = 312, $2,519; P = 0.012). ACUITY major bleeding increased cost of hospitalization by $7,894 (95%CI $4,154, $11,635; P < 0.001). CONCLUSIONS: IPTE and bleeding complications, though infrequent, are associated with substantial increased cost. These complications should be collected in economic assessments of PCI.


Assuntos
Trombose Coronária/economia , Trombose Coronária/terapia , Custos de Medicamentos , Hemorragia/economia , Hemorragia/terapia , Custos Hospitalares , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/economia , Inibidores da Agregação de Plaquetas/efeitos adversos , Inibidores da Agregação de Plaquetas/economia , Monofosfato de Adenosina/efeitos adversos , Monofosfato de Adenosina/análogos & derivados , Monofosfato de Adenosina/economia , Idoso , Clopidogrel/efeitos adversos , Clopidogrel/economia , Trombose Coronária/etiologia , Trombose Coronária/mortalidade , Análise Custo-Benefício , Método Duplo-Cego , Feminino , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Intervenção Coronária Percutânea/mortalidade , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
16.
J Am Heart Assoc ; 7(4)2018 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-29449273

RESUMO

BACKGROUND: Same-day discharge (SDD) after elective percutaneous coronary intervention is safe, less costly, and preferred by patients, but it is usually performed in low-risk patients, if at all. To increase the appropriate use of SDD in more complex patients, we implemented a "patient-centered" protocol based on risk of complications at Barnes-Jewish Hospital. METHODS AND RESULTS: Our objectives were as follows: (1) to evaluate time trends in SDD; (2) to compare (a) mortality, bleeding, and acute kidney injury, (b) patient satisfaction, and (c) hospital costs by SDD versus no SDD (NSDD); and (3) to compare SDD eligibility by our patient-centered approach versus Society for Cardiovascular Angiography and Interventions guidelines. Our patient-centered approach was based on prospectively identifying personalized bleeding, mortality, and acute kidney injury risks, with a personalized safe contrast limit and mitigating those risks. We analyzed Barnes-Jewish Hospital's National Cardiovascular Data Registry CathPCI Registry data from July 1, 2009 to September 30, 2015 (N=1752). SDD increased rapidly from 0% to 77% (P<0.001), independent of radial access. Although SDD patients were comparable to NSDD patients, SDD was not associated with adverse outcomes (0% mortality, 0% bleeds, and 0.4% acute kidney injury). Patient satisfaction was high with SDD. Propensity score-adjusted costs were $7331 lower/SDD patient (P<0.001), saving an estimated $1.8 million annually. Only 16 patients (6.95%) met the eligibility for SDD by Society for Cardiovascular Angiography and Interventions guidelines, implying our patient-centered approach markedly increased SDD eligibility. CONCLUSIONS: With a patient-centered approach, SDD rapidly increased and was safe in 75% of patients undergoing elective percutaneous coronary intervention, despite patient complexity. Patient satisfaction was high, and hospital costs were lower. Patient-centered decision making to facilitate SDD is an important opportunity to improve the value of percutaneous coronary intervention.


Assuntos
Doença da Artéria Coronariana/terapia , Tempo de Internação/tendências , Alta do Paciente/tendências , Assistência Centrada no Paciente/tendências , Intervenção Coronária Percutânea/tendências , Lesão Renal Aguda/etiologia , Idoso , Tomada de Decisão Clínica , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/mortalidade , Redução de Custos , Análise Custo-Benefício , Feminino , Hemorragia/etiologia , Custos Hospitalares , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Missouri , Alta do Paciente/economia , Satisfação do Paciente , Seleção de Pacientes , Assistência Centrada no Paciente/economia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/economia , Intervenção Coronária Percutânea/mortalidade , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
17.
JAMA Cardiol ; 2(9): 1007-1012, 2017 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-28678988

RESUMO

Importance: Acute kidney injury (AKI) after percutaneous coronary intervention (PCI) is common, morbid, and costly; increases patients' mortality risk; and can be mitigated by limiting contrast use. Objective: To examine the national variation in AKI incidence and contrast use among US physicians and the variation's association with patients' risk of developing AKI after PCI. Design, Setting, and Participants: This cross-sectional study used the American College of Cardiology National Cardiovascular Data Registry (NCDR) CathPCI Registry to identify in-hospital care for PCI in the United States. Participants included 1 349 612 patients who underwent PCI performed by 5973 physicians in 1338 hospitals between June 1, 2009, and June 30, 2012. Data analysis was performed from July 1, 2014, to August 31, 2016. Main Outcomes and Measures: The primary outcome was AKI, defined according to the Acute Kidney Injury Network criteria as an absolute increase of 0.3 mg/dL or more or a relative increase of 50% or more from preprocedural to peak creatinine. A secondary outcome was the mean contrast volume as reported in the NCDR CathPCI Registry. Physicians who performed more than 50 PCIs per year were the main exposure variable of interest. Hierarchical regression with adjustment for patients' AKI risk was used to identify the variation in AKI rates, the variation in contrast use, and the association of contrast volume with patients' predicted AKI risk. Results: Of the 1 349 612 patients who underwent PCI, the mean (SD) age was 64.9 (12.2) years, 908 318 (67.3%) were men, and 441 294 (32.7%) were women. Acute kidney injury occurred in 94 584 patients (7%). A large variation in AKI rates was observed among individual physicians ranging from 0% to 30% (unadjusted), with a mean adjusted 43% excess likelihood of AKI (median odds ratio, 1.43; 95% CI, 1.41-1.44) for statistically identical patients presenting to 2 random physicians. A large variation in physicians' mean contrast volume, ranging from 79 mL to 487 mL with an intraclass correlation coefficient of 0.23 (interquartile range, 0.21-0.25), was also observed, implying a 23% variation in contrast volume among physicians after adjustment. There was minimal correlation between contrast use and patients' AKI risk (r = -0.054). Sensitivity analysis after excluding complex cases showed that the physician variation in AKI remained unchanged. Conclusions and Relevance: Acute kidney injury rates vary greatly among physicians, who also vary markedly in their use of contrast and do not use substantially less contrast in patients with higher risk for AKI. These findings suggest an important opportunity to reduce AKI by reducing the variation in contrast volumes across physicians and lowering its use in higher-risk patients.


Assuntos
Lesão Renal Aguda/epidemiologia , Meios de Contraste/administração & dosagem , Intervenção Coronária Percutânea/métodos , Padrões de Prática Médica/estatística & dados numéricos , Sistema de Registros , Lesão Renal Aguda/induzido quimicamente , Idoso , Meios de Contraste/efeitos adversos , Estudos Transversais , Feminino , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estados Unidos/epidemiologia
18.
Am Heart J ; 186: 1-11, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28454822

RESUMO

BACKGROUND: The frequency of noncardiac chest pain (CP) hospitalization after acute myocardial infarction (AMI) is unknown, and its significance from patients' perspectives is not studied. OBJECTIVES: To assess the frequency of noncardiac CP admissions after AMI and its association with patients' self-reported health status. METHODS: We identified cardiac and noncardiac CP hospitalizations in the year after AMI from the 24-center TRIUMPH registry. Hierarchical repeated-measures regression was used to identify the association of these hospitalizations with patients' self-reported health status using the Seattle Angina Questionnaire Quality of Life domain (SAQ QoL) and Short Form 12 (SF-12) physical (PCS) and mental (MCS) component summary scores. RESULTS: Of 3,099 patients, 318 (10.3%) were hospitalized with CP, of whom 92 (28.9%) were hospitalized for noncardiac CP. Compared with patients not hospitalized with CP, noncardiac CP hospitalization was associated with poorer health status (SAQ QoL-adjusted differences: -8.9 points [95% CI -12.1 to -5.6]; SF-12 PCS: -2.5 points [95% CI -4.2 to -0.8] and SF-12 MCS: -3.5 points [95% CI -5.1 to -1.9]). The SAQ QoL for patients hospitalized with noncardiac CP was similar to patients hospitalized with cardiac CP (adjusted difference: 0.6 points [95% CI -3.2 to 4.5]; SF-12 PCS (0.9 points [95% CI -1.1 to 2.9]), but was worse with regard to SF-12 MCS (adjusted difference: -2.0 points [95% CI -3.9 to -0.2]). CONCLUSIONS: Noncardiac CP accounted for a third of CP hospitalizations within 1 year of AMI and was associated with similar disease-specific QoL as well as general physical and mental health status impairment compared with cardiac CP hospitalization.


Assuntos
Dor no Peito/etiologia , Infarto do Miocárdio/complicações , Feminino , Nível de Saúde , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/psicologia , Qualidade de Vida , Inquéritos e Questionários
19.
Clin Cardiol ; 40(8): 521-527, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28300284

RESUMO

Drug-eluting stents (DES) reduce risk of in-stent restenosis after percutaneous coronary intervention (PCI) but require dual antiplatelet therapy (DAPT) for a longer term than bare-metal stents (BMS). Few studies have examined clinical predictors of DES vs BMS, and variability in provider selection between DES and BMS in clinical practice has not been well described. These insights can inform our understanding of current practice and may identify opportunities to improve decision-making stent selection decinsion-making. In a multicenter registry, 3295 consecutive patients underwent PCI by 158 interventional cardiologists across 10 US sites. Eighty percent of patients with treated with DES. Using hierarchical regression, diabetes mellitus, multivessel disease, health insurance, and white race were independently associated with greater DES use, whereas increasing age, history of hypertension, anticipated surgery, use of warfarin, lower hemoglobin, prior history of bleeding, and treatment of right coronary and left circumflex artery lesions as compared with PCI of left anterior descending artery were associated with lower likelihood of receiving DES. Adjusted rates of DES use across providers varied from 52.3% to 94.6%, and adjusted median odds ratio for DES selection was 1.69. DES selection appeared to reflect physicians' attempts to balance benefits of DES against risks of prolonged DAPT. Nevertheless, marked residual variability in DES selection across providers persisted after adjusting for predictors of restenosis, bleeding, and other factors. Further studies are needed to better understand drivers of this variability and identify the impact of patient and provider preferences on stent selection at the time of PCI.


Assuntos
Síndrome Coronariana Aguda/terapia , Stents Farmacológicos , Metais , Intervenção Coronária Percutânea/instrumentação , Stents , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Idoso , Distribuição de Qui-Quadrado , Tomada de Decisão Clínica , Comorbidade , Reestenose Coronária/etiologia , Quimioterapia Combinada , Feminino , Disparidades em Assistência à Saúde , Hemorragia/induzido quimicamente , Humanos , Seguro Saúde , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Seleção de Pacientes , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/efeitos adversos , Padrões de Prática Médica , Desenho de Prótese , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores Socioeconômicos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
20.
JACC Cardiovasc Interv ; 10(4): 342-351, 2017 02 27.
Artigo em Inglês | MEDLINE | ID: mdl-28231901

RESUMO

OBJECTIVES: The aim of this study was to examine the independent impact of various care pathways, including those involving transradial intervention (TRI) and same-day discharge (SDD) after elective percutaneous coronary intervention (PCI), on hospital costs. BACKGROUND: PCI is associated with costs of $10 billion annually. Alternative payment models for PCI are being implemented, but few data exist on strategies to reduce costs. Various PCI care pathways, including TRI and SDD, exist, but their association with costs and outcomes is unknown. METHODS: In total, 279,987 PCI patients eligible for SDD in the National Cardiovascular Data Registry CathPCI Registry linked to Medicare claims files were analyzed. Hospital costs in 2014 U.S. dollars were estimated using cost-to-charge ratios. Propensity scores for TRI and SDD, with propensity adjustment via inverse probability weighting, was performed. RESULTS: Of the 279,987 PCI procedures, TRI was used in 9.0% (13.5% of which were SDD), and SDD was used in 5.3% of cases (23.1% of which were TRI). TRI (vs. transfemoral intervention) was associated with lower adjusted costs of $916 (95% confidence interval [CI]: $778 to $1,035), as was SDD ($3,502; 95% CI: $3,486 to $3,902). The adjusted cost associated with TRI and SDD was $13,389 (95% CI: $13,161 to $13,607), while the cost associated with transfemoral intervention and non-same-day discharge was $17,076 (95% CI: $16,999 to $17,147), a difference of $3,689 (95% CI: $3,486 to $3,902; p < 0.0001). Shifting current practice from transfemoral intervention non-same-day discharge to TRI SDD by 30% could potentially save a hospital performing 1,000 PCIs each year $1 million and the country $300 million annually. CONCLUSIONS: Among Medicare beneficiaries, TRI with SDD was independently associated with fewer complications and lower in-hospital costs. These findings have important implications for changing the current PCI care pathways to improve outcomes and reduce costs.


Assuntos
Cateterismo Periférico/economia , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/terapia , Procedimentos Clínicos/economia , Custos Hospitalares , Benefícios do Seguro/economia , Tempo de Internação/economia , Medicare/economia , Alta do Paciente/economia , Intervenção Coronária Percutânea/economia , Artéria Radial , Idoso , Idoso de 80 Anos ou mais , Cateterismo Periférico/efeitos adversos , Doença da Artéria Coronariana/diagnóstico , Redução de Custos , Análise Custo-Benefício , Feminino , Preços Hospitalares , Humanos , Modelos Lineares , Modelos Logísticos , Masculino , Modelos Econômicos , Análise Multivariada , Intervenção Coronária Percutânea/efeitos adversos , Pontuação de Propensão , Artéria Radial/diagnóstico por imagem , Sistema de Registros , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
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