Patient Access and 1-Year Outcomes of Percutaneous Coronary Intervention Facilities With and Without On-Site Cardiothoracic Surgery: Insights From the VA CART Program

Study Questions:

Is percutaneous coronary intervention (PCI) at medical facilities without on-site cardiothoracic (CT) surgery safe in real-world practice?

Methods:

Although the safety of PCI without on-site CT surgery has been established in clinical trials, its use and effectiveness, including impact on patient access and outcomes, is uncertain in other settings. The Veterans Affairs (VA) health care system has employed this strategy, with strict quality oversight, since 2005. This analysis provides insight into this question. Among 24,387 patients receiving PCI at VA facilities between October 2007 and September 2010, 6,616 (27.1%) patients underwent PCI at facilities (n = 18) without onsite CT surgery. Patient “drive time” (as a proxy for access), procedural complications, 1-year mortality, myocardial infarction (MI), and rates of subsequent revascularization procedures were compared by facility.

Results:

Results were stratified by procedural indication and PCI volume. With the inclusion of PCI facilities without on-site CT surgery, median patient drive time to the nearest PCI facility decreased by 90.8 minutes (p value < 0.001). Procedural need for emergent coronary artery bypass grafting and mortality rates were low and similar between facilities. Adjusted 1-year mortality and MI rates were similar between facilities (hazard ratio [HR] in PCI facilities without relative to those with on-site CT surgery, 1.02; 95% confidence interval [CI], 0.87-1.2), and not modified by either PCI indication or PCI volume. Subsequent revascularization rates were higher at sites without on-site CT surgery facilities (HR, 1.21; 95% CI, 1.03-1.42).

Conclusions:

The authors concluded that: 1) providing PCI facilities without on-site CT surgery in an integrated health care system does not “comprise procedural or 1-year outcomes,” and 2) patient access (measured as drive time) is significantly improved.

Perspective:

This paper adds to a growing literature on the safety and effectiveness of PCI without on-site CT surgery. I previously reviewed this topic in an important consensus document earlier this year (see Dehmer GJ, et al. J Am Coll Cardiol 2014;63:2624-41). I will repeat what I wrote then, borrowing from the paper’s conclusions that reinforce the dangers of a program built on ‘desires for personal or institutional financial gain, prestige, market share, or other similar motives.’ The paper actually went on to point out that ‘without central planning on the state or federal level,’ addressing such issues will be tough. Based on these important findings reported by Maddox et al., it appears that the VA is one such example where the need as well as safety and effectiveness of such a program have been balanced for the benefit of Veterans and their providers.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery

Keywords: Myocardial Infarction, Veterans, Delivery of Health Care, Integrated, Coronary Artery Bypass, Percutaneous Coronary Intervention


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