Interventional cardiologists’ perceptions of percutaneous coronary intervention quality measurement and feedback

Circ: Cardiovascular Quality and Outcomes

Beaver

Naranjo

et al. 2022

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Background: Prior studies of radial access for cardiac catheterization have focused on early adopters of the technique, and some have described a risk/treatment paradox of low radial access use among high bleeding risk patients. This study aimed to determine (1) trends in radial access use over time, (2) if increasing use of radial access is driven by new invasive and interventional cardiologists (operators) or existing operators changing their practice, and (3) if increasing radial rates are associated with lower bleeding rates and elimination of the risk/treatment paradox. Methods: In this cross-sectional study using data from the Clinical Assessment, Reporting, and Tracking Program, we calculated radial access rates and risk-adjusted postprocedural bleeding rates of patients undergoing diagnostic angiography or percutaneous coronary intervention (PCI) between 2011 and 2018 in Veterans Affairs hospitals. We used separate bleeding risk models for diagnostic angiography and PCI and assessed temporal trends with the Kendall Tau-b test. Results: Among 253 179 diagnostic angiograms and 93 614 PCIs, radial access rates increased over time for both diagnostic (17.5%–60.4%; P <0.01)) and PCI procedures (14.0%–51.8%; P <0.01). Existing operators and new operators increased their use at similar rates, but new operators entered practice with higher baseline rates. Nearly all operators used radial access at least once in 2018. Overall adjusted rates of bleeding declined, a trend that was significant for diagnostic angiography (2.4%–1.4%, P =0.02) but not PCI (3.4%–2.5%, P =0.20). Femoral access patients had a higher predicted risk for bleeding. Conclusions: A steady rise in radial access for diagnostic angiography and PCI was driven by increasing use among existing operators and high use by new operators. While this was associated with decreasing bleeding rates, a risk/treatment paradox for access site selection persists; patients at higher bleeding risk were still more likely to receive femoral access.

Section: Discussionmentioning

confidence: 99%

Trends in Arterial Access Site Selection and Bleeding Outcomes Following Coronary Procedures, 2011–2018

Circ: Cardiovascular Quality and Outcomes

Beaver

Naranjo

et al. 2022

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“…Instead, operators qualitatively benchmark themselves against peers regarding case selection, aggressiveness, skill, and use of contemporary techniques. 12 Confronting a PCI operator with his/her cluster profile could promote active self-reflection and drive targeted continuing medical education or peer support to address clinical gaps. A cluster 3 operator may realize, for example, that infrequent use of radial access is not an isolated indicator but is instead part of a pattern of low use of contemporary techniques and devices.…”

Section: Discussionmentioning

confidence: 99%

“…Instead, operators commonly benchmark their practice against their peers. 12 We hypothesized that clustering operators by their practice patterns will identify distinct physician profiles. This profiling is complementary to existing quality measure reporting and may allow for more effective comparisons of physicians to promote professional development and quality improvement.…”

mentioning

confidence: 99%

Percutaneous Coronary Intervention Operator Profiles and Associations With In-Hospital Mortality

Circ: Cardiovascular Interventions

Nelson

Kaltenbach

et al. 2022

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Background: Percutaneous coronary intervention is performed by operators with differing experience, technique, and case mix. It is unknown if operator practice patterns impact patient outcomes. We sought to determine if a cluster algorithm can identify distinct profiles of percutaneous coronary intervention operators and if these profiles are associated with patient outcomes. Methods: Operators performing at least 25 annual procedures between 2014 and 2018 were clustered using an agglomerative hierarchical clustering algorithm. Risk-adjusted in-hospital mortality was compared between clusters. Results: We identified 4 practice profiles among 7706 operators performing 2 937 419 procedures. Cluster 1 (n=3345) demonstrated case mix and practice patterns similar to the national median. Cluster 2 (n=1993) treated patients with lower clinical acuity and were less likely to use intracoronary diagnostics, atherectomy, and radial access. Cluster 3 (n=1513) had the lowest case volume, were more likely to work at rural hospitals, and cared for a higher proportion of patients with ST-segment–elevation myocardial infarction and cardiogenic shock. Cluster 4 (n=855) had the highest case volume, were most likely to treat patients with high anatomic complexity and use atherectomy, intracoronary diagnostics, and mechanical support. Compared with cluster 1, adjusted in-hospital mortality was similar for cluster 2 (estimated difference, −0.03 [95% CI, −0.10 to 0.04]), higher for cluster 3 (0.14 [0.07–0.22]), and lower for cluster 4 (−0.15 [−0.24 to −0.06]). Conclusions: Distinct percutaneous coronary intervention operator profiles are differentially associated with patient outcomes. A phenotypic approach to physician assessment may provide actionable feedback for quality improvement.

“…Even experienced operators may benefit from peer support and advanced preparation. 23 In addition, accurate risk adjustment is essential for reporting and comparison of PCI outcomes. Prior studies have shown that public reporting of PCI mortality is associated with risk avoidant behavior, leading to undertreatment of high-risk patients, and overall worse patient outcomes.…”

Section: Discussionmentioning

confidence: 99%

Contemporary Clinical and Coronary Anatomic Risk Model for 30-Day Mortality After Percutaneous Coronary Intervention

Circ: Cardiovascular Interventions

O’Donnell

Plomondon

et al. 2021

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Background: Percutaneous coronary intervention (PCI) procedures are increasing in clinical and anatomic complexity, likely increasing the calculated risk of mortality. There is need for a real-time risk prediction tool that includes clinical and coronary anatomic information that is integrated into the electronic medical record system. Methods: We assessed 70 503 PCIs performed in 73 Veterans Affairs hospitals from 2008 to 2019. We used regression and machine-learning strategies to develop a prediction model for 30-day mortality following PCI. We assessed model performance with and without inclusion of the Veterans Affairs SYNTAX score (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery), an assessment of anatomic complexity. Finally, the discriminatory ability of the Veterans Affairs model was compared with the CathPCI mortality model. Results: The overall 30-day morality rate was 1.7%. The final model included 14 variables. Presentation status (salvage, emergent, urgent), ST-segment–elevation myocardial infarction, cardiogenic shock, age, congestive heart failure, prior valve disease, chronic kidney disease, chronic lung disease, atrial fibrillation, elevated international normalized ratio, and the Veterans Affairs SYNTAX score were all associated with increased risk of death, while increasing body mass index, hemoglobin level, and prior coronary artery bypass graft surgery were associated with lower risk of death. C-index for the development cohort was 0.93 (95% CI, 0.92–0.94) and for the 2019 validation cohort and the site validation cohort was 0.87 (95% CI, 0.83–0.92) and 0.86 (95% CI, 0.83–0.89), respectively. The positive likelihood ratio of predicting a mortality event in the top decile was 2.87% more accurate than the CathPCI mortality model. Inclusion of anatomic information in the model resulted in significant improvement in model performance (likelihood ratio test P <0.01). Conclusions: This contemporary risk model accurately predicts 30-day post-PCI mortality using a combination of clinical and anatomic variables. This can be immediately implemented into clinical practice to promote personalized informed consent discussions and appropriate preparation for high-risk PCI cases.