title: Patient access and 1-year outcomes of percutaneous coronary intervention facilities with and without on-site cardiothoracic surgery: insights from the Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking (CART) program.
abstract: BACKGROUND
  The safety of percutaneous coronary intervention (PCI) at medical facilities without on-site cardiothoracic (CT) surgery has been established in clinical trials. However, the comparative effectiveness of this strategy in real-world practice, including impact on patient access and outcomes, is uncertain. The Veterans Affairs (VA) health care system has used this strategy, with strict quality oversight, since 2005, and can provide insight into this question.
  
  
  RESULTS
  Among 24,387 patients receiving PCI at VA facilities between October 2007 and September 2010, 6616 (27.1%) patients underwent PCI at facilities (n=18) without on-site CT surgery. Patient drive time (as a proxy for access), procedural complications, 1-year mortality, myocardial infarction, and rates of subsequent revascularization procedures were compared by facility. Results were stratified by procedural indication (ST-segment-elevation myocardial infarction versus non-ST-segment-elevation myocardial infarction/unstable angina versus elective) and PCI volume. With the inclusion of PCI facilities without on-site CT surgery, median drive time for patients treated at those facilities decreased by 90.8 minutes (P<0.001). Procedural need for emergent coronary artery bypass graft and mortality rates were low and similar between facilities. Adjusted 1-year mortality and myocardial infarction rates were similar between facilities (hazard ratio in PCI facilities without relative to those with on-site CT surgery, 1.02; 95% confidence interval, 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 (hazard ratio, 1.21; 95% confidence interval, 1.03-1.42).
  
  
  CONCLUSIONS
  This study suggests that providing PCI facilities without on-site CT surgery in an integrated health care system with quality oversight improves patient access without compromising procedural or 1-year outcomes.
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); University of Colorado School of Medicine, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); Kaiser Permanente Colorado, Denver, CO (T.T.T.); Jesse Brown VA Medical Center, Chicago, IL (A.R.S., B.S.); and Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC (R.J.J.). thomas.maddox@va.gov.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Maddox
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); University of Colorado School of Medicine, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); Kaiser Permanente Colorado, Denver, CO (T.T.T.); Jesse Brown VA Medical Center, Chicago, IL (A.R.S., B.S.); and Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC (R.J.J.).
authors.forename: Maggie A
authors.initials: MA
authors.lastname: Stanislawski
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); University of Colorado School of Medicine, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); Kaiser Permanente Colorado, Denver, CO (T.T.T.); Jesse Brown VA Medical Center, Chicago, IL (A.R.S., B.S.); and Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC (R.J.J.).
authors.forename: Colin
authors.initials: C
authors.lastname: O'Donnell
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); University of Colorado School of Medicine, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); Kaiser Permanente Colorado, Denver, CO (T.T.T.); Jesse Brown VA Medical Center, Chicago, IL (A.R.S., B.S.); and Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC (R.J.J.).
authors.forename: Mary E
authors.initials: ME
authors.lastname: Plomondon
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); University of Colorado School of Medicine, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); Kaiser Permanente Colorado, Denver, CO (T.T.T.); Jesse Brown VA Medical Center, Chicago, IL (A.R.S., B.S.); and Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC (R.J.J.).
authors.forename: Steven M
authors.initials: SM
authors.lastname: Bradley
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); University of Colorado School of Medicine, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); Kaiser Permanente Colorado, Denver, CO (T.T.T.); Jesse Brown VA Medical Center, Chicago, IL (A.R.S., B.S.); and Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC (R.J.J.).
authors.forename: P Michael
authors.initials: PM
authors.lastname: Ho
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); University of Colorado School of Medicine, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); Kaiser Permanente Colorado, Denver, CO (T.T.T.); Jesse Brown VA Medical Center, Chicago, IL (A.R.S., B.S.); and Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC (R.J.J.).
authors.forename: Thomas T
authors.initials: TT
authors.lastname: Tsai
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); University of Colorado School of Medicine, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); Kaiser Permanente Colorado, Denver, CO (T.T.T.); Jesse Brown VA Medical Center, Chicago, IL (A.R.S., B.S.); and Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC (R.J.J.).
authors.forename: Adhir R
authors.initials: AR
authors.lastname: Shroff
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); University of Colorado School of Medicine, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); Kaiser Permanente Colorado, Denver, CO (T.T.T.); Jesse Brown VA Medical Center, Chicago, IL (A.R.S., B.S.); and Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC (R.J.J.).
authors.forename: Bernadette
authors.initials: B
authors.lastname: Speiser
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); University of Colorado School of Medicine, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); Kaiser Permanente Colorado, Denver, CO (T.T.T.); Jesse Brown VA Medical Center, Chicago, IL (A.R.S., B.S.); and Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC (R.J.J.).
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Jesse
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); University of Colorado School of Medicine, Denver, CO (T.M.M., M.A.S., C.O., M.E.P., S.M.B., P.M.H., T.T.T., J.S.R.); Kaiser Permanente Colorado, Denver, CO (T.T.T.); Jesse Brown VA Medical Center, Chicago, IL (A.R.S., B.S.); and Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC (R.J.J.).
authors.forename: John S
authors.initials: JS
authors.lastname: Rumsfeld
mesh_terms: D000368:Aged; D000789:Angina, Unstable / Q000401:mortality / Q000601:surgery / Q000628:therapy; D001026:Coronary Artery Bypass / Q000401:mortality*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality* / Q000601:surgery / Q000628:therapy; D017063:Outcome Assessment, Health Care; D010355:Patient Identification Systems / Q000706:statistics & numerical data; D062645:Percutaneous Coronary Intervention / Q000401:mortality*; D012042:Registries / Q000706:statistics & numerical data*; D015607:Stents / Q000706:statistics & numerical data; D014481:United States; D014493:United States Department of Veterans Affairs / Q000706:statistics & numerical data*
keywords: angioplasty; registries; stents; surgery