Operators at cardiac catheterization laboratories across Veterans Affairs (VA) hospitals reported stable outcomes over recent years, despite an increasingly complex patient population.
The numbers of coronary angiography and percutaneous coronary intervention (PCI) procedures performed remained fairly constant from 2009 to 2015, although with a sharp uptick in transradial access from 6% to 36% and 5% to 32%, respectively (both P<0.001).
During this time, the treated population got older and went into their procedures with more comorbidities, as determined by the Framingham and National Cardiovascular Data Registry CathPCI risk scores, a group of investigators led by Stephen Waldo, MD, of VA Eastern Colorado Healthcare System in Denver, reported in the May 14 issue of JACC: Cardiovascular Interventions.
Procedural complications and clinical outcomes, meanwhile, remained constant, perhaps with a trend for reduced mortality risk following PCI (HR 0.983, 95% CI 0.967-1.000), according to the data from the VA Clinical Assessment, Reporting, and Tracking Program.
“Taken together, the data suggest that the increasing medical complexity with time has not led to worsening of clinical outcomes for patients in the VA health care system. Furthermore, the complication rates observed in the largest integrated health care system in the United States compare very favorably with the voluntary reporting in similar community-based programs,” Waldo’s group concluded.
“These data highlight the potential benefits of an integrated healthcare system using a heart team approach as well as a central organization to monitor the overall quality and safety of invasive cardiac procedures,” they added.
Their dataset was comprised of patients undergoing coronary angiography alone (n=194,476) or with an intervention (n=85,024) in the VA system.
Another observation from their study was the lack of change in medical management over time.
“Previous data have demonstrated that approximately one-half of patients undergoing interventions at private or community institutions were prescribed antiplatelet agents, angiotensin antagonists, beta-blockers, and statins in a contemporary cohort. In the present analysis, the prescription of these medications exceeded that prescribed in the community such that three-fourths of patients undergoing percutaneous revascularization in the VA system were treated with all four classes of medications at discharge,” according to Waldo and colleagues.
Limitations affecting generalizability included the mostly male patient population and low representation of various racial groups in this dataset, noted Jennifer Rymer, MD, and Manesh Patel, MD, both of Duke University Medical Center in Durham, N.C., in an accompanying editorial.
Additionally, the lack of 24-hour catheterization labs in many VA facilities resulted in less than 6% of total interventions in the analysis being for cases of ST-segment elevation MI, according to the editorialists, arguing against any direct comparison between VA and non-VA hospitals regarding complication rates.
The investigators acknowledged that their dependence on administrative records left room for entry errors and the omission of readmissions if they were at non-VA centers.
Nevertheless, interventional cardiology clearly will have to keep up with the shifts in patient demographics, the editorialists suggested. For example, real-time data capture and feedback on cardiac catheterization lab outcomes and discharge practices will be “critical” for appropriate patient selection and management of an increasingly complex and older patient population, they wrote.
“Now well into its fourth decade, interventional cardiology is a mature field with advanced stent technology, effective evidence-based medications, and dual antiplatelet therapy, and evolved techniques to reduce access site bleeding,” Rymer and Patel wrote. “Given the already evolved nature of the field, the current focus is on defining and measuring quality of care to improve access site decisions with increased uptake of transradial access, appropriate discharge prescribing of secondary [medications], and to reduce procedural complications in more complex patients.”
Waldo declared getting institutional research support from Abiomed, Cardiovascular Systems, and Merck.
Rymer reported no relevant conflicts of interest.
Patel disclosed receiving research funding from AstraZeneca and Janssen and serving on advisory boards for Janssen and Bayer.
F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner