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Who fares better: patients undergoing percutaneous coronary intervention (PCI) at safety net hospitals, or non-safety net hospitals?
The answer, according to research published in JACC: Cardiovascular Interventions, is that outcomes didn’t differ much as one might assume.
The significance, according to the study team led by University of California, San Francisco (UCSF) researchers, is that U.S. safety net hospitals (SNHs), which serve the nation's most vulnerable patients and provide care to many patients who are low income and/or uninsured or underinsured, as well as to patients who have insurance, generally have fewer resources than do other hospitals.
"The patients treated at safety net hospitals often have critical heart problems and other health issues that, in many cases, have not been adequately managed," explained senior study author John Ambrose, MD, emeritus chief of cardiology and a professor of medicine at UCSF. "Therefore, the fact that these hospitals are able to keep mortality rates low and achieve these outcomes when performing PCI — nearly matching non-safety net hospitals — is quite remarkable."
Researchers drew data from the American College of Cardiology's National Cardiovascular Data Registry (NCDR) CathPCI Registry from 2009 to 2015. For the purposes of the study, a safety net hospital was defined as having a PCI volume of at least 10% for patients without insurance, based on the Agency for Healthcare Research and Quality’s definition.
Included were data from 3,746,961 patients who underwent PCI at 282 SNHs and 1,134 non-SNHs. Results indicate that risk-adjusted in-hospital mortality was only slightly higher in the safety net hospitals — i.e., four additional patients per 1,000 cases of PCI — than in non-SNHs.
In general, patients having the procedure performed at SNHs were younger, had more risk factors, and were more likely to have been admitted through the ED because of a ST-segment elevation myocardial infarction.
Both types of hospitals had similar rates of risk-adjusted bleeding and acute kidney injury — which are adverse events associated with PCI procedures, the authors added, noting that only events that occurred while in the hospital were tracked.
The study authors reported that patients undergoing PCI at SNHs had higher risk-adjusted in-hospital mortality — odds ratio: 1.23 — although the absolute risk difference between groups was small at 0.4%. Risk-adjusted bleeding (odds ratio: 1.05), and acute kidney injury rates (odds ratio: 1.01) also were similar.
"Clinical care is often complex. Because of that, it can be hard to make comparisons to understand what type of care is contributing to a positive outcome and what isn't," Ambrose said. "However, with this study, we now know that the hospital itself was not a significant factor in determining how well a patient did after their PCI procedure. The similarities we found also suggested that we can use the current NCDR risk model as a foundation for future comparisons between safety net and non-safety net hospitals."
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