Relationship Between Operator Volume and Long-Term Outcomes After Percutaneous Coronary Intervention: Report From the NCDR CathPCI Registry
Relationship Between Operator Volume and Long-Term Outcomes After Percutaneous Coronary Intervention: Report From the NCDR CathPCI Registry
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DOI：
10.1161/circulationaha.117.033325
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发表时间：
2019-01-22
期刊：
影响因子：
37.8
通讯作者：
Rao, Sunil V.
中科院分区：
文献类型：
--
作者：
Fanaroff, Alexander C.;Zakroysky, Pearl;Rao, Sunil V.
背景：尽管许多研究显示手术容积与经皮冠状动脉介入治疗（PCI）后短期不良结果呈负相关，但手术容积与长期结果之间的关系尚不清楚。方法：使用国家心血管数据注册中心（CathPCI）注册数据与医疗保险索赔数据相关联，我们检查了65岁患者的手术量与长期预后之间的关系。操作者按年平均PCI量进行分层（计算所有年龄段患者的PCI）：低（100）量的操作者。采用Kaplan-Meier方法计算1年未调整死亡率和主要不良冠状动脉事件（mace，定义为死亡、心肌梗死再入院或计划外冠状动脉血运重建术）。不符合比例风险假设，从PCI至出院时间和出院至1年随访时间分别计算操作人员数量与结果的风险调整相关性。结果：2009年7月1日至2014年12月31日期间，8936名操作人员进行了723644例PCI手术，其中高容量操作人员2553例，中等容量操作人员2878例，低容量操作人员3505例。与大容量和中等容量的运营商相比，小容量运营商更经常进行急诊PCI，他们的患者心血管合并症更少。在1年的随访中，15.9%的小容量手术组患者发生MACE，而16.9%的大容量手术组患者发生MACE （P=0.004）。多变量调整后，中等和高容量手术者的院内死亡率显著低于低容量手术者（优势比为0.91；中等与低的95% CI为0.86-0.96；优势比为0.79；高与低的95% CI为0.75-0.83）。从出院到1年随访，操作者队列间mace、死亡、心肌梗死或计划外血运重建率无显著差异（mace的校正风险比为0.99；中、低的95% CI为0.96-1.01；风险比为1.01；高、低的95% CI为0.99-1.04）。结论：接受年容积较高的操作人员治疗的老年人PCI术后未经调整的1年预后更差；然而，接受这些手术的患者有更多的心血管合并症。风险调整后，手术量越大，住院死亡率越低，出院后mace无差异。
Background: Although many studies show an inverse association between operator procedural volume and short-term adverse outcomes after percutaneous coronary intervention (PCI), the association between procedural volume and longer-term outcomes is unknown.Methods: Using the National Cardiovascular Data Registry CathPCI registry data linked with Medicare claims data, we examined the association between operator PCI volume and long-term outcomes among patients 65 years of age. Operators were stratified by average annual PCI volume (counting PCIs performed in patients of all ages): low- (100) volume operators. One-year unadjusted rates of death and major adverse coronary events (MACEs; defined as death, readmission for myocardial infarction, or unplanned coronary revascularization) were calculated with Kaplan-Meier methods. The proportional hazards assumption was not met, and risk-adjusted associations between operator volume and outcomes were calculated separately from the time of PCI to hospital discharge and from hospital discharge to 1-year follow-up.Results: Between July 1, 2009, and December 31, 2014, 723644 PCI procedures were performed by 8936 operators: 2553 high-, 2878 intermediate-, and 3505 low-volume operators. Compared with high- and intermediate-volume operators, low-volume operators more often performed emergency PCI, and their patients had fewer cardiovascular comorbidities. Over 1-year follow-up, 15.9% of patients treated by low-volume operators had a MACE compared with 16.9% of patients treated by high-volume operators (P=0.004). After multivariable adjustment, intermediate- and high-volume operators had a significantly lower rate of in-hospital death than low-volume operators (odds ratio, 0.91; 95% CI, 0.86-0.96 for intermediate versus low; odds ratio, 0.79; 95% CI, 0.75-0.83 for high versus low). There were no significant differences in rates of MACEs, death, myocardial infarction, or unplanned revascularization between operator cohorts from hospital discharge to 1-year follow-up (adjusted hazard ratio for MACEs, 0.99; 95% CI, 0.96-1.01 for intermediate versus low; hazard ratio, 1.01; 95% CI, 0.99-1.04 for high versus low).Conclusions: Unadjusted 1-year outcomes after PCI were worse for older adults treated by operators with higher annual volume; however, patients treated by these operators had more cardiovascular comorbidities. After risk adjustment, higher operator volume was associated with lower in-hospital mortality and no difference in postdischarge MACEs.