VA Puget Sound Health Care System, Seattle, Washington; Division of Cardiology, University of Washington, Seattle, Washington.
Duke Clinical Research Institute, Durham, North Carolina.
JACC Cardiovasc Interv. 2017 Apr 10;10(7):672-682. doi: 10.1016/j.jcin.2016.12.019.
This study sought to determine variability and stability in risk-standardized mortality rates (RSMR) of percutaneous coronary intervention (PCI) operators meeting minimum case volume standards and identify differences in case mix and practice patterns that may account for RSMR variability.
RSMR has been suggested as a metric to evaluate the performance of PCI operators; however, variability of operator-level RSMR and the stability of this metric over time among the same operator are unknown.
The authors calculated mean RSMRs for PCI operators with average annual volume of ≥50 cases in the National Cardiovascular Data Registry CathPCI Registry. Funnel plots were used to account for operator case volume. Demographic, clinical, and treatment variables of patients treated by operators with outlying high or low RSMRs (identified by RMSR greater than or less than 2 σ above or below the mean [analogous to 2 SD], respectively) were compared with nonoutlier operators. RMSR stability was assessed by calculating average annual operator RMSR during the study period and by determining if operators were consistently classified into RMSR categories in each year.
Between October 1, 2009, and September 30, 2014, a total of 2,352,174 PCIs were performed at 1,373 hospitals by 3,760 operators. Of these, 242 operators (6.5%) had RSMR >2 σ above the mean and 156 operators (4.1%) had RSMR >2 σ below the mean. Both high and low RSMR outlier operators treated patients with lower expected mortality risk, compared with nonoutlier operators. There was significant instability in annual operator RMSR during the study period.
There is significant variability in risk-standardized PCI mortality among U.S. operators meeting minimum volume standards that is not explained by case mix or procedure characteristics. Operator RMSR was unstable from year to year, thus limiting its utility as a sole performance measure for PCI quality.
本研究旨在确定符合最低病例量标准的经皮冠状动脉介入治疗（PCI）术者的风险标准化死亡率（RSMR）的变异性和稳定性，并确定可能导致 RSMR 变异性的病例组合和实践模式差异。
RSMR 已被提议作为评估 PCI 术者表现的指标；然而，术者层面的 RSMR 的变异性以及同一术者在不同时间点 RSMR 的稳定性尚不清楚。
作者计算了国家心血管数据注册中心 CathPCI 注册中心中平均每年 PCI 病例量≥50 例的 PCI 术者的平均 RSMR。使用漏斗图来考虑术者的病例量。对 RSMR 偏高或偏低（定义为高于或低于平均值的 2σ[相当于 2 个标准差]）的术者治疗的患者的人口统计学、临床和治疗变量与非异常术者进行比较。通过计算研究期间每个术者的平均年度术者 RSMR 以及确定术者是否在每年都被一致归类到 RSMR 类别中，来评估 RSMR 的稳定性。
2009 年 10 月 1 日至 2014 年 9 月 30 日期间，共有 1373 家医院的 3760 名术者进行了 2352174 例 PCI。其中，242 名术者（6.5%）的 RSMR 高于平均值的 2σ，156 名术者（4.1%）的 RSMR 低于平均值的 2σ。与非异常术者相比，RSMR 偏高和偏低的术者治疗的患者的预期死亡率风险较低。在研究期间，术者每年的 RSMR 变化显著。
符合最低病例量标准的美国 PCI 术者的风险标准化 PCI 死亡率存在显著的变异性，无法用病例组合或手术特征来解释。术者的 RSMR 年复一年地不稳定，因此限制了其作为 PCI 质量的唯一绩效衡量指标的使用。
