Abstract 162: Procedural and 1-Year Outcomes between PCI Centers with and without On-Site CT Surgery: Insights from the VA CART Program

Abstract

Background: Clinical trials demonstrate that percutaneous coronary intervention (PCI) can be safely performed at medical centers without on-site cardiothoracic (CT) surgery, and current PCI guidelines support this practice with effective quality oversight. Translation of these trial findings and guideline recommendations into clinical practice has not been described. In 2005, the VA initiated a policy to expand PCI access by performing procedures at centers without on-site CT surgery under strict quality standards. The impact of this policy on procedural and longer-term patient outcomes has not been evaluated. Methods: We studied all PCIs conducted in the VA health care system between 2007-2010. We used data from the VA Clinical Assessment, Reporting, and Tracking (CART) Program, a national clinical quality program that collects real-time data on coronary procedures, procedural complications, and outcomes. Procedural complications (need for emergent CABG and in-lab death), 1-year all-cause mortality, myocardial infarction (MI), and rates of repeat revascularization procedures were compared by presence of on-site CT surgery. We used multivariate survival analysis to assess the association between the presence of on-site CT surgery and 1-year outcomes. The analyses were further stratified by procedural indication (ACS vs. elective) and cath lab PCI volume (≥ vs. <165 PCIs/year). Results: 24,387 patients received a PCI at 59 centers in the VA health care system between 2007-2010. 6,900 (28.3%) patients underwent PCI at 19 centers without on-site CT surgery. Rates of procedural complications were similar for PCI centers with and without on-site CT surgery (emergent CABG: 13 (0.1%) at PCI centers with on-site CT surgery vs. 2 (<0.05%) at PCI centers without on-site CT surgery, p-value 0.26; deaths: 15 (0.1%) at PCI centers with on-site CT surgery vs. 5 (0.1%) at PCI centers without on-site CT surgery, p-value 0.74). Adjusted 1-year combined all-cause mortality and MI rates were similar between centers (HR 0.995, 95% CI 0.84, 1.17), but revascularization rates were higher at sites without on-site CT surgery centers (HR 1.20, 95% CI 1.05, 1.33). Neither PCI indication nor cath lab volume significantly modified these results. Conclusions: Our findings demonstrate that procedural and 1-year patient outcomes are similar between PCI centers with and without on-site CT surgery. These results indicate that the clinical trial evidence of PCI safety without on-site CT surgery can be effectively translated to clinical practice. The VA’s policy allowing for PCI centers without on-site CT surgery in the setting of a quality oversight program may serve as a potential model for improving PCI access in large, integrated health care systems.