Center for Outcomes Research, The Children's Hospital of Philadelphia, PA.
Department of Anesthesiology and Critical Care, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
J Am Heart Assoc. 2018 May 25;7(11):e008366. doi: 10.1161/JAHA.117.008366.
Coronary atherosclerosis raises the risk of acute myocardial infarction (AMI), and is usually included in AMI risk-adjustment models. Percutaneous coronary intervention (PCI) does not cause atherosclerosis, but may contribute to the notation of atherosclerosis in administrative claims. We investigated how adjustment for atherosclerosis affects rankings of hospitals that perform PCI.
This was a retrospective cohort study of 414 715 Medicare beneficiaries hospitalized for AMI between 2009 and 2011. The outcome was 30-day mortality. Regression models determined the association between patient characteristics and mortality. Rankings of the 100 largest PCI and non-PCI hospitals were assessed with and without atherosclerosis adjustment. Patients admitted to PCI hospitals or receiving interventional cardiology more frequently had an atherosclerosis diagnosis. In adjustment models, atherosclerosis was associated, implausibly, with a 42% reduction in odds of mortality (odds ratio=0.58, <0.0001). Without adjustment for atherosclerosis, the number of expected lives saved by PCI hospitals increased by 62% (<0.001). Hospital rankings also changed: 72 of the 100 largest PCI hospitals had better ranks without atherosclerosis adjustment, while 77 of the largest non-PCI hospitals had worse ranks (<0.001).
Atherosclerosis is almost always noted in patients with AMI who undergo interventional cardiology but less often in medically managed patients, so adjustment for its notation likely removes part of the effect of interventional treatment. Therefore, hospitals performing more extensive imaging and more PCIs have higher atherosclerosis diagnosis rates, making their patients appear healthier and artificially reducing the expected mortality rate against which they are benchmarked. Thus, atherosclerosis adjustment is detrimental to hospitals providing more thorough AMI care.
冠状动脉粥样硬化会增加急性心肌梗死（AMI）的风险，通常包含在 AMI 风险调整模型中。经皮冠状动脉介入治疗（PCI）不会引起动脉粥样硬化，但可能会导致行政索赔中动脉粥样硬化的记录。我们研究了调整动脉粥样硬化对执行 PCI 的医院排名的影响。
这是一项回顾性队列研究，纳入了 2009 年至 2011 年期间因 AMI 住院的 414715 名 Medicare 受益人的数据。主要终点为 30 天死亡率。回归模型确定了患者特征与死亡率之间的关系。在有无动脉粥样硬化调整的情况下，评估了 100 家最大的 PCI 和非 PCI 医院的排名。接受 PCI 治疗的患者或接受介入心脏病学治疗的患者更频繁地被诊断为动脉粥样硬化。在调整模型中，动脉粥样硬化与死亡率降低 42%（比值比=0.58，<0.0001）的关联令人难以置信。在没有动脉粥样硬化调整的情况下，PCI 医院可以多挽救 62%的预计寿命（<0.001）。医院排名也发生了变化：在没有动脉粥样硬化调整的情况下，100 家最大的 PCI 医院中有 72 家排名上升，而最大的 77 家非 PCI 医院排名下降（<0.001）。
在接受介入心脏病学治疗的 AMI 患者中几乎总是记录有动脉粥样硬化，但在接受药物治疗的患者中则较少记录，因此调整其记录可能会消除部分介入治疗的效果。因此，进行更多广泛成像和更多 PCI 的医院有更高的动脉粥样硬化诊断率，这使他们的患者看起来更健康，并人为地降低了他们作为基准的预期死亡率。因此，动脉粥样硬化调整对提供更全面 AMI 护理的医院不利。
