Sherwood Matthew W, Brennan J Matthew, Ho Kalon K, Masoudi Frederick A, Messenger John C, Weaver W Douglas, Dai David, Peterson Eric D
Division of Cardiovascular Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina.
Division of Cardiovascular Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina.
JACC Cardiovasc Interv. 2015 Jan;8(1 Pt A):10-6. doi: 10.1016/j.jcin.2014.07.025. Epub 2014 Dec 10.
The goal of this study was to examine the calibration of a validated risk-adjustment model in very high-risk percutaneous coronary intervention (PCI) cases and assess whether sites' case mix affects their performance ratings.
There are concerns that treating PCI patients with particularly high-risk features such as cardiogenic shock or prior cardiac arrest may adversely impact hospital performance ratings. However, there is little investigation on the validity of these concerns.
We examined 624,286 PCI procedures from 1,168 sites that participated in the CathPCI Registry in 2010. Procedural risk was estimated using the recently published Version 4 National Cardiovascular Data Registry (NCDR) PCI risk-adjusted mortality (RAM) model. We calculated observed/expected mortality using several risk classification methods, and simulated hospital performance after combining their highest risk cases over 2 years into a single year.
In 2010, crude in-hospital PCI mortality was 1.4%. The NCDR model was generally well calibrated among high risk, however there was slight overprediction of risk in extreme cases. Hospitals treating the highest overall expected risk PCI patients or those treating the top 20% of high-risk cases had lower (better) RAM ratings than centers treating lower-risk cases (1.25% vs. 1.51%). The observed/expected ratio for top-risk quintile versus low-risk quintile was 0.91 (0.87 to 0.96) versus 1.10 (1.03 to 1.17). Combining all the high-risk patients over a 2-year period into a single year also did not negatively impact the site's RAM ratings.
Evaluation of a contemporary sample of PCI cases across the United States showed no evidence that treating high-risk PCI cases adversely affects hospital RAM rates.
本研究的目的是检验一个经过验证的风险调整模型在极高风险经皮冠状动脉介入治疗（PCI）病例中的校准情况，并评估各机构的病例组合是否会影响其绩效评级。
有人担心，治疗具有特别高风险特征的PCI患者，如心源性休克或既往心脏骤停患者，可能会对医院绩效评级产生不利影响。然而，对于这些担忧的有效性几乎没有进行调查。
我们检查了2010年参与心脏导管PCI注册研究的1168个机构的624286例PCI手术。使用最近发布的第4版国家心血管数据注册研究（NCDR）PCI风险调整死亡率（RAM）模型估计手术风险。我们使用几种风险分类方法计算观察到的/预期的死亡率，并模拟将各机构2年中最高风险病例合并到单一年度后的医院绩效。
2010年，PCI住院患者的粗死亡率为1.4%。NCDR模型在高风险患者中总体校准良好，但在极端情况下风险预测略有高估。治疗总体预期风险最高的PCI患者的医院或治疗前20%高风险病例的医院，其RAM评级低于治疗低风险病例的中心（1.25%对1.51%）。最高风险五分位数与低风险五分位数的观察到的/预期的比率分别为0.91（0.87至0.96）和1.10（1.03至1.17）。将2年期间所有高风险患者合并到单一年度也未对机构的RAM评级产生负面影响。
对美国当代PCI病例样本的评估表明，没有证据表明治疗高风险PCI病例会对医院的RAM率产生不利影响。
