Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri.
Barnes-Jewish Hospital, St Louis, Missouri.
JAMA Cardiol. 2017 Sep 1;2(9):1007-1012. doi: 10.1001/jamacardio.2017.2156.
Acute kidney injury (AKI) after percutaneous coronary intervention (PCI) is common, morbid, and costly; increases patients' mortality risk; and can be mitigated by limiting contrast use.
To examine the national variation in AKI incidence and contrast use among US physicians and the variation's association with patients' risk of developing AKI after PCI.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used the American College of Cardiology National Cardiovascular Data Registry (NCDR) CathPCI Registry to identify in-hospital care for PCI in the United States. Participants included 1 349 612 patients who underwent PCI performed by 5973 physicians in 1338 hospitals between June 1, 2009, and June 30, 2012. Data analysis was performed from July 1, 2014, to August 31, 2016.
The primary outcome was AKI, defined according to the Acute Kidney Injury Network criteria as an absolute increase of 0.3 mg/dL or more or a relative increase of 50% or more from preprocedural to peak creatinine. A secondary outcome was the mean contrast volume as reported in the NCDR CathPCI Registry. Physicians who performed more than 50 PCIs per year were the main exposure variable of interest. Hierarchical regression with adjustment for patients' AKI risk was used to identify the variation in AKI rates, the variation in contrast use, and the association of contrast volume with patients' predicted AKI risk.
Of the 1 349 612 patients who underwent PCI, the mean (SD) age was 64.9 (12.2) years, 908 318 (67.3%) were men, and 441 294 (32.7%) were women. Acute kidney injury occurred in 94 584 patients (7%). A large variation in AKI rates was observed among individual physicians ranging from 0% to 30% (unadjusted), with a mean adjusted 43% excess likelihood of AKI (median odds ratio, 1.43; 95% CI, 1.41-1.44) for statistically identical patients presenting to 2 random physicians. A large variation in physicians' mean contrast volume, ranging from 79 mL to 487 mL with an intraclass correlation coefficient of 0.23 (interquartile range, 0.21-0.25), was also observed, implying a 23% variation in contrast volume among physicians after adjustment. There was minimal correlation between contrast use and patients' AKI risk (r = -0.054). Sensitivity analysis after excluding complex cases showed that the physician variation in AKI remained unchanged.
Acute kidney injury rates vary greatly among physicians, who also vary markedly in their use of contrast and do not use substantially less contrast in patients with higher risk for AKI. These findings suggest an important opportunity to reduce AKI by reducing the variation in contrast volumes across physicians and lowering its use in higher-risk patients.
经皮冠状动脉介入治疗（PCI）后发生急性肾损伤（AKI）较为常见，且病情严重、医疗费用高；增加了患者的死亡风险；通过限制造影剂的使用，可以减轻 AKI 的发生。
研究美国医生中 AKI 发生率和造影剂使用的全国差异，以及这种差异与 PCI 后患者发生 AKI 风险的关系。
设计、环境和参与者：本横断面研究使用美国心脏病学会国家心血管数据注册（NCDR）CathPCI 注册中心，确定了美国的 PCI 院内护理。参与者包括 2009 年 6 月 1 日至 2012 年 6 月 30 日期间，由 5973 名医生在 1338 家医院进行的 1349612 例 PCI。数据分析于 2014 年 7 月 1 日至 2016 年 8 月 31 日进行。
主要结局为 AKI，根据急性肾损伤网络标准定义为术前至峰值肌酐水平绝对增加 0.3mg/dL 或更多，或相对增加 50%或更多。次要结局为 NCDR CathPCI 注册中心报告的平均造影剂用量。每年行超过 50 例 PCI 的医生是主要的感兴趣暴露变量。使用调整患者 AKI 风险的分层回归，以确定 AKI 发生率的变化、造影剂使用的变化，以及造影剂体积与患者预测 AKI 风险的关系。
在 1349612 例接受 PCI 的患者中，平均（SD）年龄为 64.9（12.2）岁，908318 例（67.3%）为男性，441294 例（32.7%）为女性。94584 例（7%）患者发生 AKI。观察到个别医生之间 AKI 发生率存在较大差异，范围为 0%至 30%（未调整），对于统计学上相同的患者，呈现给 2 名随机医生后，AKI 的调整后平均 43%的额外可能性（中位数优势比，1.43；95%CI，1.41-1.44）。还观察到医生平均造影剂体积的较大差异，范围为 79 毫升至 487 毫升，组内相关系数为 0.23（四分位距，0.21-0.25），这意味着在调整后医生之间造影剂体积的差异为 23%。造影剂使用与患者 AKI 风险之间的相关性很小（r=-0.054）。排除复杂病例后的敏感性分析表明，医生间 AKI 的变化保持不变。
AKI 发生率在医生之间差异很大，他们在造影剂使用方面也有很大差异，并且在 AKI 风险较高的患者中并未明显减少造影剂的使用。这些发现表明，通过减少医生之间造影剂用量的差异，并降低高危患者的造影剂使用量，有机会显著减少 AKI 的发生。
