Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan.
Division of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan.
PLoS One. 2021 Dec 13;16(12):e0261371. doi: 10.1371/journal.pone.0261371. eCollection 2021.
Large-scale registries have demonstrated that in-hospital mortality after percutaneous coronary intervention (PCI) varies widely across institutions. However, whether this variation is related to major procedural complications (e.g., bleeding) is unclear. In this study, institutional variation in in-hospital mortality and its association with PCI-related bleeding complications were investigated. We analyzed 388,866 procedures at 718 hospitals performed from 2017 to 2018, using data from a nationwide PCI registry in Japan. Hospitals were stratified into quintiles according to risk-adjusted in-hospital mortality (very low, low, medium, high, and very high). Incidence of bleeding complications, defined as procedure-related bleeding events that required a blood transfusion, and in-hospital mortality in patients who developed bleeding complications were calculated for each quintile. Overall, 4,048 (1.04%) in-hospital deaths and 1,535 (0.39%) bleeding complications occurred. Among patients with bleeding complications, 270 (17.6%) died during hospitalization. In-hospital mortality ranged from 0.22% to 2.46% in very low to very high mortality hospitals. The rate of bleeding complications varied modestly from 0.27% to 0.57% (odds ratio, 1.95; 95% confidence interval, 1.58-2.39). However, mortality after bleeding complications markedly increased by quintile and was 6-fold higher in very high mortality hospitals than very low mortality hospitals (29.0% vs. 4.8%; odds ratio, 12.2; 95% confidence interval, 6.90-21.7). In conclusion, institutional variation in in-hospital mortality after PCI was associated with procedure-related bleeding complications, and this variation was largely driven by differences in mortality after bleeding complications rather than difference in their incidence. These findings underscore the importance of efforts toward reducing not only bleeding complications but also, even more importantly, subsequent mortality once they have occurred.
大规模注册研究表明，经皮冠状动脉介入治疗（PCI）后的院内死亡率在各机构之间差异很大。然而，这种差异是否与主要的手术并发症（如出血）有关尚不清楚。本研究旨在调查 PCI 相关出血并发症与院内死亡率之间的关系。我们分析了 2017 年至 2018 年期间日本全国 PCI 注册研究中的 718 家医院的 388866 例手术数据。根据风险调整后的院内死亡率（极低、低、中、高和极高），将医院分为五分位数。计算每个五分位数的出血并发症发生率（定义为需要输血的与手术相关的出血事件）和发生出血并发症患者的院内死亡率。总的来说，有 4048 例（1.04%）院内死亡和 1535 例（0.39%）出血并发症。在发生出血并发症的患者中，有 270 例（17.6%）在住院期间死亡。院内死亡率从极低死亡率医院的 0.22%到极高死亡率医院的 2.46%不等。出血并发症的发生率从 0.27%到 0.57%（比值比，1.95；95%置信区间，1.58-2.39）略有不同。然而，出血并发症后的死亡率随着五分位数的增加而显著增加，极高死亡率医院的死亡率是极低死亡率医院的 6 倍（29.0% vs. 4.8%；比值比，12.2；95%置信区间，6.90-21.7）。总之，PCI 后院内死亡率的机构间差异与手术相关的出血并发症有关，这种差异主要是由出血并发症后死亡率的差异而不是出血并发症发生率的差异驱动的。这些发现强调了不仅要减少出血并发症，而且更重要的是一旦发生，还要降低随后的死亡率的努力的重要性。
