Singh Mandeep, Gersh Bernard J, Lennon Ryan J, Ting Henry H, Holmes David R, Doyle Brendan J, Rihal Charanjit S
Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
Mayo Clin Proc. 2009 Jun;84(6):501-8. doi: 10.4065/84.6.501.
To compare outcomes of percutaneous coronary interventions (PCIs) at 2 community hospitals without on-site surgery (Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital) with a center with on-site surgery (Saint Marys Hospital).
Using a matched case-control design, we studied 1842 elective and 667 nonelective PCI procedures (myocardial infarction [MI]/cardiogenic shock) performed from January 1, 1999, through December 31, 2007. The quality assurance protocol included operator volume and training, application of a risk-adjustment model, transport protocol, and database participation. We compared in-hospital mortality and/or emergent coronary artery bypass surgery after PCI at Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital, which do not have on-site surgery, with Saint Marys Hospital, a medical center with the capability to perform coronary artery bypass grafting on site.
Of 22 baseline variables, significant imbalances between matched groups were present in only 3 (hyperlipidemia, history of MI, American College of Cardiology/American Heart Association B2/C type lesion) in the elective group and 2 (Canadian Cardiovascular Society class III/IV angina, multivessel disease) in the nonelective group. The primary end point occurred in 0.3%, 0.1%, and 0.6% of patients undergoing elective PCI (P=.07) and 3.3%, 3.3%, and 3.7% of patients undergoing nonelective PCI (P=.65) at Immanuel St. Joseph's Hospital, Franciscan Skemp Healthcare, and Saint Marys Hospital, respectively. The in-hospital mortality rate at Immanuel St. Joseph's Hospital and Franciscan Skemp Healthcare was comparable to that at Saint Marys Hospital for both elective (0.3%, 0.1%, 0.4%; P=.24) and nonelective PCI (2.6%, 2.4%, 3.1%; P=.49). No patient undergoing elective PCI required transfer for emergency cardiac surgery. Of the 21 transfers, 20 (95%) were in the setting of MI and cardiogenic shock or left main/3-vessel disease; 18 patients (86%) survived to discharge.
Optimal outcomes with PCI have been observed at community hospitals without on-site cardiac surgical programs with application of a prospective, standardized quality assurance protocol.
比较两家无现场手术的社区医院（方济各会斯肯普医疗中心和伊曼纽尔圣约瑟夫医院）与一家有现场手术的中心医院（圣玛丽医院）进行经皮冠状动脉介入治疗（PCI）的结果。
采用匹配病例对照设计，我们研究了1999年1月1日至2007年12月31日期间进行的1842例择期和667例非择期PCI手术（心肌梗死[MI]/心源性休克）。质量保证方案包括术者手术量和培训、风险调整模型的应用、转运方案以及数据库参与情况。我们比较了方济各会斯肯普医疗中心和伊曼纽尔圣约瑟夫医院（这两家医院无现场手术）与圣玛丽医院（一家有能力现场进行冠状动脉旁路移植术的医疗中心）PCI术后的院内死亡率和/或急诊冠状动脉旁路移植手术情况。
在22个基线变量中，择期组仅3个变量（高脂血症、MI病史、美国心脏病学会/美国心脏协会B2/C型病变）以及非择期组仅2个变量（加拿大心血管学会III/IV级心绞痛、多支血管病变）在匹配组之间存在显著失衡。伊曼纽尔圣约瑟夫医院、方济各会斯肯普医疗中心和圣玛丽医院择期PCI患者的主要终点发生率分别为0.3%、0.1%和0.6%（P = 0.07），非择期PCI患者的主要终点发生率分别为3.3%、3.3%和3.7%（P = 0.65）。伊曼纽尔圣约瑟夫医院和方济各会斯肯普医疗中心择期PCI（0.3%、0.1%、0.4%；P = 0.24）和非择期PCI（2.6%、2.4%、3.1%；P = 0.49）的院内死亡率与圣玛丽医院相当。接受择期PCI的患者均无需转往进行急诊心脏手术。在21例转院中，20例（95%）是在MI和心源性休克或左主干/三支血管病变的情况下；18例患者（86%）存活至出院。
通过应用前瞻性、标准化的质量保证方案，在没有现场心脏手术项目的社区医院中观察到了PCI的最佳结果。
