From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.N.V., D.D., T.Y.W., M.T.R., M.R.P., E.D.P., S.V.R.); Department of Cardiovascular Medicine, University of Michigan, Ann Arbor (H.G.); Division of Cardiology, Washington University School of Medicine, St. Louis, MO (A.P.A.); Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora (J.C.M.); Division of Cardiovascular Medicine, Department of Medicine, University of California-San Diego (E.M.); Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (L.M.); Harvard Clinical Research Institute, Boston, MA (L.M.); Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (J.C.); and University of Vermont Cardiovascular Research Institute, Burlington, VT (H.L.D.).
Circ Cardiovasc Interv. 2016 Mar;9(3):e003070. doi: 10.1161/CIRCINTERVENTIONS.115.003070.
Because of recent changes in criteria for coverage for inpatient hospital stays, most nonacute percutaneous coronary intervention (PCI) procedures are reimbursed on an outpatient basis regardless of underlying patient risk. Downstream effects of these changes on the risk profile of patients undergoing outpatient PCI have not been evaluated.
Using the American College of Cardiology National Cardiovascular Data Registry's CathPCI Registry, we assessed temporal trends in risk profiles and rates of hospital admission among 999 279 patients undergoing PCI qualifying for outpatient reimbursement. We estimated mortality and bleeding risk using validated models from the registry. From 2009 to 2014, the proportion of outpatients not admitted to a hospital after PCI increased from 32.8% to 66.3% (P<0.001). Patients who were admitted after PCI were older, had greater comorbidities, and experienced more post-PCI complications (all P<0.001). Among those not admitted, the proportion of patients at high risk for predicted mortality increased significantly from 17.0% to 19.8% during the study period (P<0.001). In contrast, 16.7% of patients admitted after PCI were at low risk for mortality.
Among patients undergoing PCI procedures that qualify for outpatient reimbursement, there has been a temporal decrease in postprocedure hospital admission. Concomitantly, the proportion of these outpatients at high risk for mortality has significantly increased over time. These data suggest that current reimbursement classification could be improved by incorporating patient risk to appropriately match the necessary resources to the needed level of care.
由于最近住院患者住院费用覆盖标准的变化，大多数非急性经皮冠状动脉介入治疗（PCI）程序无论患者的潜在风险如何，都以门诊的形式报销。这些变化对接受门诊 PCI 的患者的风险状况的后续影响尚未评估。
我们使用美国心脏病学会国家心血管数据注册中心的 CathPCI 注册中心，评估了 999279 名符合门诊报销条件的接受 PCI 患者的风险概况和住院率的时间趋势。我们使用该注册中心的验证模型估计死亡率和出血风险。从 2009 年到 2014 年，PCI 后未住院的门诊患者比例从 32.8%增加到 66.3%（P<0.001）。PCI 后住院的患者年龄更大，合并症更多，并且经历更多的 PCI 后并发症（均 P<0.001）。在未住院的患者中，预测死亡率高风险的患者比例从研究期间的 17.0%显著增加到 19.8%（P<0.001）。相比之下，16.7%的 PCI 后住院患者死亡风险低。
在符合门诊报销条件的 PCI 患者中，PCI 术后住院的时间呈下降趋势。同时，这些门诊患者中死亡风险高的比例也随着时间的推移显著增加。这些数据表明，目前的报销分类可以通过纳入患者风险来改善，以将必要的资源与所需的护理水平相匹配。
