Watanabe Atsuyuki, Miyamoto Yoshihisa, Ueyama Hiroki A, Gotanda Hiroshi, Jentzer Jacob C, Kapur Navin K, Jorde Ulrich P, Tsugawa Yusuke, Kuno Toshiki
Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY (A.W.).
Department of Real-World Evidence, The University of Tokyo, Japan (Y.M.).
Circ Cardiovasc Interv. 2024 Dec;17(12):e014738. doi: 10.1161/CIRCINTERVENTIONS.124.014738. Epub 2024 Oct 29.
Percutaneous microaxial ventricular assist devices (pVADs) have the potential to reduce mortality of patients with cardiogenic shock (CS). However, the association between the distribution of pVAD-performing centers and outcomes of CS has not been explored.
This observational study included Medicare fee-for-service beneficiaries aged 65 to 99 years treated with pVAD for CS from 2016 to 2020. It examined the associations between patient outcomes and 2 exposure variables: hospitals' procedure volumes of pVAD and patient-hospital distances (in quintiles [Qn]). We developed Cox proportional hazards regression for 180-day mortality and heart failure readmission rates, and multivariable logistic regression for in-hospital outcomes, adjusting for patient demographics, comorbidities, concomitant treatments, and hospital characteristics, including CS volume, teaching status, and the ability to perform extracorporeal membrane oxygenation.
A total of 6637 patients with CS underwent pVAD at 1041 hospitals, with the annualized hospital volume ranging widely from 0.3 to 55.6 cases/year. Patients treated at higher-volume centers experienced lower 180-day mortality compared with those treated at lower-volume centers (Qn1=reference; Qn2: adjusted hazard ratio [aHR], 0.88 [95% CI, 0.79-0.97]; Qn3: aHR, 0.88 [95% CI, 0.79-0.98]; Qn4: aHR, 0.88 [95% CI, 0.78-0.99]; Qn5: aHR, 0.84 [95% CI, 0.74-0.95]; for trend, 0.026), while we found no evidence that patient-hospital distances were associated with mortality (Qn1=reference; Qn2: aHR, 0.99 [95% CI, 0.89-1.09]; Qn3: aHR, 0.94 [95% CI, 0.85-1.04]; Qn4: aHR, 1.01 [95% CI, 0.92-1.11]; Qn5: aHR, 0.91 [95% CI, 0.82-1.01]; for trend, 0.160). We found no evidence that the hospital volume and patient-hospital distances were associated with in-hospital bleeding, intracranial hemorrhage, or renal replacement therapy initiation.
Hospital volume was more strongly associated with mortality than patient-hospital distances, suggesting that rational distribution of pVAD-performing centers while ensuring adequate procedure volumes may optimize patient mortality.
经皮微轴心室辅助装置（pVADs）有降低心源性休克（CS）患者死亡率的潜力。然而，尚未探讨pVAD植入中心的分布与CS患者结局之间的关联。
这项观察性研究纳入了2016年至2020年接受pVAD治疗CS的65至99岁医疗保险按服务收费受益人。研究了患者结局与两个暴露变量之间的关联：医院的pVAD手术量和患者与医院的距离（分为五分位数[Qn]）。我们针对180天死亡率和心力衰竭再入院率建立了Cox比例风险回归模型，针对住院结局建立了多变量逻辑回归模型，并对患者人口统计学、合并症、伴随治疗以及医院特征（包括CS病例数、教学状况和进行体外膜肺氧合的能力）进行了调整。
共有6637例CS患者在1041家医院接受了pVAD植入，各医院的年手术量差异很大，从每年0.3例至55.6例不等。与在手术量较低的中心接受治疗的患者相比，在手术量较高的中心接受治疗的患者180天死亡率更低（Qn1 = 参照组；Qn2：调整后风险比[aHR]，0.88[95%置信区间，0.79 - 0.97]；Qn3：aHR，0.88[95%置信区间，0.79 - 0.98]；Qn4：aHR，0.88[95%置信区间，0.78 - 0.99]；Qn5：aHR，0.84[95%置信区间，0.74 - 0.95]；趋势检验P = 0.026），而我们没有发现证据表明患者与医院的距离与死亡率相关（Qn1 = 参照组；Qn2：aHR，0.99[95%置信区间，0.89 - 1.09]；Qn3：aHR，0.94[95%置信区间，0.85 - 1.04]；Qn4：aHR，1.01[95%置信区间，0.92 - 1.11]；Qn5：aHR，0.91[95%置信区间，0.82 - 1.01]；趋势检验P = 0.160）。我们没有发现证据表明医院手术量和患者与医院的距离与住院期间出血、颅内出血或开始肾脏替代治疗有关。
医院手术量比患者与医院的距离与死亡率的关联更强，这表明在确保有足够手术量的同时合理分布pVAD植入中心可能会优化患者死亡率。
