Hospital Volume Outcomes After Septal Myectomy and Alcohol Septal Ablation for Treatment of Obstructive Hypertrophic Cardiomyopathy US Nationwide Inpatient Database, 2003-2011
Hospital Volume Outcomes After Septal Myectomy and Alcohol Septal Ablation for Treatment of Obstructive Hypertrophic Cardiomyopathy US Nationwide Inpatient Database, 2003-2011
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DOI：
10.1001/jamacardio.2016.0252
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发表时间：
2016-06-01
期刊：
影响因子：
24
通讯作者：
Feldman, Dmitriy N.
中科院分区：
文献类型：
--
作者：
Kim, Luke K.;Swaminathan, Rajesh V.;Feldman, Dmitriy N.
重要性以往关于梗阻性肥厚型心肌病的间隔肌切开术(SM)和酒精间隔消融术(ASA)的数据仅限于小型、非随机、单中心研究。目的在一个大型的国家住院患者数据库中，研究SM和ASA按医院容量分层后的住院结果。设计、设置和参与者：本研究分析了2003年1月1日至2011年12月31日在全国住院数据库中因SM或ASA住院的所有患者的预后和不良住院事件(死亡、中风、出血、急性肾功能衰竭和需要永久起搏器)的发生率。结果71888 761例出院记录中，11248例接受了房间隔缩小手术，其中房间隔缩小6386例(56.8%)，房间隔缩小4862例(43.2%)。在研究期间，总共59.9%的机构进行了10次或更少的SM程序，而66.9%的机构进行了10次或更少的ASA程序。SM后住院死亡率(15.6%、9.6%和3.8%；P<；.001)、需要永久起搏器的发生率(10.0%、13.8%和8.9%；P<；.001)和出血并发症(3.3%、3.8%和1.7%；P<；.001)分别以医院容量的1/3、1/3和1/3分层时，高容量中心的发生率较低。同样，在高容量中心接受ASA治疗后，死亡率(2.3%、0.8%和0.6%；P=0.02)和急性肾功能衰竭(6.2%、7.6%和2.4%；P<；.001)较低。医院中SM量最低的三分位数是院内全因死亡率(调整后的优势比，3.11；95%可信区间，1.98-4.89)和出血(调整后的优势比，3.77；95%CI，2.12-6.70)，而按容量计算处于ASA最低三分位数的患者并不独立地与术后不良事件风险的增加相关。结论与相关性：从2003年到2011年，在美国医院中，大多数提供间隔缩小治疗的中心很少进行SM和ASA手术，这低于2011年美国心脏病学会基金会/美国心脏协会工作组肥厚型心肌病诊断和治疗指南推荐的阈值。低SM量与较差的结果相关，包括更高的死亡率、更长的住院时间和更高的费用。需要更多的努力来鼓励患者转诊到卓越的间隔缩小治疗中心。
IMPORTANCE Previous data on septal myectomy (SM) and alcohol septal ablation (ASA) in obstructive hypertrophic cardiomyopathy have been limited to small, nonrandomized, single-center studies. Use of septal reduction therapy and the effect of institutional experience on procedural outcomes nationally are unknown.OBJECTIVE To examine in-hospital outcomes after SM and ASA stratified by hospital volume within a large, national inpatient database.DESIGN, SETTING, AND PARTICIPANTS This study analyzed all patients who were hospitalized for SM or ASA in a nationwide inpatient database from January 1, 2003, through December 31,2011.MAIN OUTCOMES AND MEASURES Rates of adverse in-hospital events (death, stroke, bleeding, acute renal failure, and need for permanent pacemaker) were examined. Multivariate logistic regression analysis was performed to compare overall outcomes after each procedure based on tertiles of hospital volume of SM and ASA.RESULTS Of 71888 761 discharge records reviewed, a total of 11248 patients underwent septal reduction procedures, of whom 6386 (56.8%) underwent SM and 4862 (43.2%) underwent ASA. A total of 59.9% of institutions performed 10 SM procedures or fewer, whereas 66.9% of institutions performed 10 ASA procedures or fewer during the study period. Incidence of in-hospital death (15.6%, 9.6%, and 3.8%; P < .001), need for permanent pacemaker (10.0%, 13.8%, and 8.9%; P < .001), and bleeding complications (3.3%, 3.8%, and 1.7%; P < .001) after SM was lower in higher-volume centers when stratified by first, second, and third tertiles of hospital volume, respectively. Similarly, there was a lower incidence of death (2.3%, 0.8%, and 0.6%; P = .02) and acute renal failure (6.2%, 7.6%, and 2.4%; P < .001) after ASA in higher-volume centers. The lowest tertile of SM volume among hospitals was an independent predictor of in-hospital all-cause mortality (adjusted odds ratio, 3.11; 95% CI, 1.98-4.89) and bleeding (adjusted odds ratio, 3.77; 95% CI, 2.12-6.70), whereas being in the lowest tertile of ASA by volume was not independently associated with an increased risk of adverse postprocedural events.CONCLUSIONS AND RELEVANCE In US hospitals from 2003 through 2011, most centers that provide septal reduction therapy performed few SM and ASA procedures, which is below the threshold recommended by the 2011 American College of Cardiology Foundation/American Heart Association Task Force Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy. Low SM volume was associated with worse outcomes, including higher mortality, longer length of stay, and higher costs. More efforts are needed to encourage referral of patients to centers of excellence for septal reduction therapy.