Percutaneous Coronary Interventions in Facilities Without Cardiac Surgery On Site: A Report From the National Cardiovascular Data Registry (NCDR)

Kutcher, Michael A.; Klein, Lloyd W.; Ou, Fang‐Shu; Wharton, Thomas P.; Dehmer, Gregory J.; Singh, Mandeep; Anderson, H. Vernon; Rumsfeld, John S.; Weintraub, William S.; Shaw, Richard E.; Sacrinty, Matthew; Woodward, Albert; Peterson, Eric D.; Brindis, Ralph G.

doi:10.1016/j.jacc.2009.03.038

Cited by 77 publications

(61 citation statements)

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“…3,21 Observational studies exploring the safety of PCI facilities without on-site CT surgery have generally supported these trial findings. [6][7][8][9][10] Current PCI guidelines assign a Class IIa (is reasonable) recommendation for primary PCI and Class IIb (might be considered) recommendation for elective PCI at facilities without on-site CT surgery services with appropriate program development and quality oversight. 11 However, concerns have persisted that variable patient case-mix and PCI volume may contribute to worse real-world outcomes among off-site CT surgery facilities.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4][5] Observational studies exploring the safety of PCI facilities without on-site CT surgery have generally supported these trial findings. [6][7][8][9][10] As a result, current PCI guidelines allow for the procedure at facilities without on-site CT surgery, but call for appropriate program development and quality oversight. 11 However, significant questions about this strategy remain unanswered, including its impact on patient access, longer-term outcomes, and the exact nature of effective quality oversight.…”

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confidence: 99%

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Patient Access and 1-Year Outcomes of Percutaneous Coronary Intervention Facilities With and Without On-Site Cardiothoracic Surgery

et al. 2014

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The US Department of Veterans Affairs (VA) has the largest integrated health care delivery system in the nation and serves a large number of veterans living in rural locations. In an effort to improve patients' access to cardiology services, the VA began offering PCI programs at facilities without on-site CT surgery in 2005, coupled with strict quality oversight. Specifically, it established a national clinical quality oversight program-the Clinical Assessment, Reporting, and Tracking (CART) Program-for all VA cath labs that collected real-time data on cath laboratory Background-The safety of percutaneous coronary intervention (PCI) at medical facilities without on-site cardiothoracic (CT) surgery has been established in clinical trials. However, the comparative effectiveness of this strategy in real-world practice, including impact on patient access and outcomes, is uncertain. The Veterans Affairs (VA) health care system has used this strategy, with strict quality oversight, since 2005, and can provide insight into this question. Methods and Results-Among 24 387 patients receiving PCI at VA facilities between October 2007 and September 2010, 6616 (27.1%) patients underwent PCI at facilities (n=18) without on-site CT surgery. Patient drive time (as a proxy for access), procedural complications, 1-year mortality, myocardial infarction, and rates of subsequent revascularization procedures were compared by facility. Results were stratified by procedural indication (ST-segment-elevation myocardial infarction versus non-ST-segment-elevation myocardial infarction/unstable angina versus elective) and PCI volume. With the inclusion of PCI facilities without on-site CT surgery, median drive time for patients treated at those facilities decreased by 90.8 minutes (P<0.001). Procedural need for emergent coronary artery bypass graft and mortality rates were low and similar between facilities. Adjusted 1-year mortality and myocardial infarction rates were similar between facilities (hazard ratio in PCI facilities without relative to those with on-site CT surgery, 1.02; 95% confidence interval, 0.87-1.2), and not modified by either PCI indication or PCI volume. Subsequent revascularization rates were higher at sites without on-site CT surgery facilities (hazard ratio, 1.21; 95% confidence interval, 1.03-1.42). Conclusions-This study suggests that providing PCI facilities without on-site CT surgery in an integrated health care system with quality oversight improves patient access without compromising procedural or 1-year outcomes.

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Patient Access and 1-Year Outcomes of Percutaneous Coronary Intervention Facilities With and Without On-Site Cardiothoracic Surgery

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“…[10][11][12][13][14] In this issue of JAMA, Singh and colleagues 15 report on a meta-analysis of largely observational studies that extends the results of earlier meta-analyses from these and other authors. 16,17 The studies included in this analysis span the prestent era (before 1994), the bare-metal stent era (1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004), and the drug-eluting stent eras (after 2004).…”

Section: Va Author Manuscriptmentioning

confidence: 76%

“…12,13 Also, it is unclear how deaths after transfer from a non-CABG surgical hospital are counted. Some registries try to ascertain deaths after nonemergency transfers for CABG surgery 11 ; however, this is not the rule. Similarly, deaths occurring among patients with successful PCI after transfer to a tertiary hospital for complications (eg, heart failure) may not be counted as in-hospital deaths for the referring non-CABG surgical hospital.…”

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The Trials and Tribulations of Percutaneous Coronary Intervention in Hospitals Without On-site CABG Surgery

Kinlay¹

2011

JAMA

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Historically, on-site coronary artery bypass grafting (CABG) surgery was not only required for percutaneous coronary angioplasty but operating rooms were also usually on standby until the angioplasty procedure was deemed successful. 1 In the 1980s, abrupt and subacute closure of the coronary artery at the angioplasty site due to dissection and associated thrombus, were not uncommon and 5% to 10% of patients required emergency CABG or CABG surgery within 24 hours. 2 Bail-out coronary stenting, for which stents are used to treat a dissection or abrupt closure after balloon angioplasty, revolutionized percutaneous coronary interventions (PCIs) by preventing periprocedural myocardial infarction and reducing the need for emergency CABG surgery. Subsequent randomized trials showed that primary stenting (stenting as a primary strategy) offered greater procedural success and lower rates of restenosis than balloon angioplasty and bail-out stenting. 3,4 More recently, with primary stenting, the risk of requiring emergency CABG surgery is now 10 times lower than it was in the early balloon angioplasty era (<0.5%). 5,6 Events are rare, because stents and other technologies successfully treat all but the most catastrophic complications of PCI.The move to establish PCIs in hospitals without on-site CABG surgical facilities started with several trials that showed better outcomes with primary PCI than with thrombolytic therapy for ST-elevation myocardial infarction (STEMI). 5 These benefits were expected because PCI is a more definitive treatment for the culprit coronary lesion and because thrombolytic therapy has defined risks of hemorrhagic stroke. Initial studies demonstrated that a strategy of transferring patients to centers with CABG surgery for primary PCI resulted in better outcomes than local treatment with thrombolysis. 7 Subsequently, in the Atlantic Cardiovascular Patient Outcomes Research Team (C-PORT) study, 8 better outcomes were achieved with local PCI in centers without CABG surgery than with thrombolytic therapy. Although no randomized trial tested primary PCI in centers without CABG surgery vs transfer for PCI in centers with CABG surgery, supporters argued that local PCI would permit more rapid and greater access to primary PCI for patients with STEMI. U.S. Department of Veterans Affairs VA Author ManuscriptVA Author Manuscript VA Author ManuscriptHowever, transportation time is less of an issue for PCI among the much larger pool of patients with non-STEMI and stable angina. For these patients, PCI in hospitals without onsite CABG surgery is based on patient convenience and the low absolute risk of death and emergency CABG surgery in carefully selected patients. Also, providing PCI services offers other benefits for an institution such as prestige in the community and the promise of handsome remuneration from procedural, professional, and hospitalization fees.Numerous registry studies comparing PCI outcomes in centers with or without CABG surgery show similar rates of in-hospital mortality and emergency CA...

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“…Since 2006, 11 original studies and 3 meta-analyses on the topic of PCI without on-site surgery have been identified by a computerized systematic literature search using Medline (PubMed and Ovid) and Cochrane Databases [9,[11][12][13][14][15][16][17][18][19][20][21][22][23].…”

Section: Recent Literature On Pci Without On-site Surgerymentioning

confidence: 99%

SCAI/ACC/AHA Expert Consensus Document

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et al. 2014

Cathet Cardio Intervent

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Percutaneous Coronary Interventions in Facilities Without Cardiac Surgery On Site: A Report From the National Cardiovascular Data Registry (NCDR)

Cited by 77 publications

References 28 publications

Patient Access and 1-Year Outcomes of Percutaneous Coronary Intervention Facilities With and Without On-Site Cardiothoracic Surgery

Patient Access and 1-Year Outcomes of Percutaneous Coronary Intervention Facilities With and Without On-Site Cardiothoracic Surgery

The Trials and Tribulations of Percutaneous Coronary Intervention in Hospitals Without On-site CABG Surgery

SCAI/ACC/AHA Expert Consensus Document

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