Bradley Steven M, Chan Paul S, Spertus John A, Kennedy Kevin F, Douglas Pamela S, Patel Manesh R, Anderson H Vernon, Ting Henry H, Rumsfeld John S, Nallamothu Brahmajee K
VA Eastern Colorado Health Care System, Denver, CO 80220-3808, USA.
Circ Cardiovasc Qual Outcomes. 2012 May;5(3):290-7. doi: 10.1161/CIRCOUTCOMES.112.966044. Epub 2012 May 10.
Measurement of hospital quality has traditionally focused on processes of care and postprocedure outcomes. Appropriateness measures for percutaneous coronary intervention (PCI) assess quality as it relates to patient selection and the decision to perform PCI. The association between patient selection for PCI and processes of care and postprocedural outcomes is unknown.
We included 203 531 patients undergoing nonacute (elective) PCI from 779 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry between July 2009 and April 2011. We examined the association between a hospital's proportion of nonacute PCIs categorized as inappropriate by the 2009 Appropriate Use Criteria (AUC) for Coronary Revascularization and in-hospital mortality, bleeding complications, and use of optimal guideline-directed medical therapy at discharge (ie, aspirin, thienopyridines, and statins). When categorized as hospital tertiles, the range of inappropriate PCI was 0.0% to 8.1% in the lowest tertile, 8.1% to 15.2% in the middle tertile, and 15.2% to 58.6% in the highest tertile. Compared with lowest-tertile hospitals, mortality was not significantly different at middle-tertile (adjusted odds ratio [OR], 0.93; 95% confidence interval [CI], 0.73-1.19) or highest-tertile hospitals (OR, 1.12; 95% CI, 0.88-1.43; P=0.35 for differences between tertiles). Similarly, risk-adjusted bleeding did not vary significantly (middle-tertile OR, 1.13; 95% CI, 1.02-1.16; highest-tertile OR, 1.02; 95% CI, 0.91-1.16; P=0.07 for differences between tertiles) nor did use of optimal medical therapy at discharge (85.3% versus 85.7% versus 85.2%; P=0.58).
In a national cohort of nonacute PCIs, a hospital's proportion of inappropriate PCIs was not associated with in-hospital mortality, bleeding, or medical therapy at discharge. This suggests PCI appropriateness measures aspects of hospital PCI quality that are independent of how well the procedure is performed. Therefore, PCI appropriateness and postprocedural outcomes are both important metrics to inform PCI quality.
医院质量的衡量传统上侧重于护理过程和术后结果。经皮冠状动脉介入治疗（PCI）的适宜性衡量标准评估与患者选择及进行PCI的决策相关的质量。PCI患者选择与护理过程及术后结果之间的关联尚不清楚。
我们纳入了2009年7月至2011年4月期间参与国家心血管数据注册库（NCDR）CathPCI注册研究的779家医院中接受非急性（择期）PCI的203531例患者。我们研究了一家医院被2009年冠状动脉血运重建适宜性使用标准（AUC）归类为不适当的非急性PCI比例与院内死亡率、出血并发症以及出院时使用最佳指南指导药物治疗（即阿司匹林、噻吩吡啶类和他汀类药物）之间的关联。当按医院三分位数分类时，最低三分位数中不适当PCI的范围为0.0%至8.1%，中间三分位数为8.1%至15.2%，最高三分位数为15.2%至58.6%。与最低三分位数的医院相比，中间三分位数（调整后的优势比[OR]，0.93；95%置信区间[CI]，0.73 - 1.19）或最高三分位数的医院死亡率无显著差异（OR，1.12；95% CI，0.88 - 1.43；三分位数之间差异的P = 0.35）。同样，风险调整后的出血情况无显著差异（中间三分位数OR，1.13；95% CI，1.02 - 1.16；最高三分位数OR，1.02；95% CI，0.91 - 1.16；三分位数之间差异的P = 0.07），出院时使用最佳药物治疗的情况也无显著差异（分别为85.3%、85.7%和85.2%；P = 0.58）。
在一组全国性的非急性PCI患者中，医院不适当PCI的比例与院内死亡率、出血或出院时的药物治疗无关。这表明PCI适宜性衡量了医院PCI质量中与手术执行情况无关的方面。因此，PCI适宜性和术后结果都是反映PCI质量的重要指标。
