title: Outcomes and Temporal Trends of Inpatient Percutaneous Coronary Intervention at Centers With and Without On-site Cardiac Surgery in the United States.
abstract: There are concerns whether percutaneous coronary intervention (PCI) at centers without on-site cardiac surgery is safe outside of a tightly regulated research environment.
  
  
  
  To analyze the outcomes and temporal trends of inpatient PCI at centers without on-site cardiac surgery in an unselected and nationally representative population of the United States.
  
  
  
  A national inpatient sample (N = 6 912 232) was used to identify patients who underwent inpatient PCI in the United States from January 1, 2003, to December 31, 2012. Hospitals that performed 1 or more coronary artery bypass graft surgeries in a given calendar year were classified as centers with on-site cardiac surgery, and weighted sampling of all inpatient hospitalizations was performed. Data analysis was performed from February to May 2016.
  
  
  
  Inpatient PCI.
  
  
  
  In-hospital mortality.
  
  
  
  Of the 6 912 232 inpatient PCIs performed, 2 336 334 patients (33.8%) were women and 4 575 898 (66.2%) were men; their mean (SD) age was 64.5 (12.3) years. Of these PCIs, 396 741 (5.7%) were conducted at centers without on-site cardiac surgery. The rate of in-hospital mortality was significantly lower at centers with on-site cardiac surgery compared with centers without on-site cardiac surgery (1.4% vs 1.9%; unadjusted odds ratio [OR], 0.74; 95% CI, 0.72-0.75). After adjustment, there was no significant difference in in-hospital mortality between centers with and without on-site cardiac surgery (OR, 1.01; 95% CI, 0.98-1.03; P = .62) for acute coronary syndromes and elective procedures requiring inpatient hospitalization. In addition, there were no significant differences in the risk-adjusted, in-hospital mortality between the 2 groups in prespecified subgroups after adjusting for multiple comparisons, including ST-elevation myocardial infarction (OR, 0.99; 95% CI, 0.96-1.03; P = .65), non-ST-elevation acute coronary syndrome (OR, 0.99; 95% CI, 0.93-1.05; P = .66), and elective PCI (OR, 0.93; 95% CI, 0.84-1.03; P = .17). There was a significant increase in the proportion of PCIs at centers without on-site cardiac surgery within the study period (from 1.8% to 12.7%; P < .001 for trend by Cochrane-Armitage test) reflected across all the indications.
  
  
  
  There was a 7-fold increase in the proportion of PCIs at centers without on-site cardiac surgery from 2003 to 2012 in the United States, with the adjusted in-hospital mortality after inpatient PCI being similar at centers with and without on-site cardiac surgery. These data provide evidence that PCI at centers without on-site cardiac surgery may be safe in the modern era.
authors.affiliation: Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Kashish
authors.initials: K
authors.lastname: Goel
authors.affiliation: Division of Cardiology, New York Medical College, Valhalla3Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Tanush
authors.initials: T
authors.lastname: Gupta
authors.affiliation: Division of Cardiology, Brown University, Providence, Rhode Island.
authors.forename: Dhaval
authors.initials: D
authors.lastname: Kolte
authors.affiliation: Division of Cardiology, New York Medical College, Valhalla.
authors.forename: Sahil
authors.initials: S
authors.lastname: Khera
authors.affiliation: David Geffen School of Medicine, UCLA (University of California, Los Angeles)6Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology.
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.affiliation: Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts.
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
authors.affiliation: Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Mandeep
authors.initials: M
authors.lastname: Singh
authors.affiliation: Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Charanjit S
authors.initials: CS
authors.lastname: Rihal
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass / Q000379:methods* / Q000401:mortality; D003430:Cross-Sectional Studies; D017558:Elective Surgical Procedures; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000601:surgery*; D016017:Odds Ratio; D063868:Patient Outcome Assessment; D062645:Percutaneous Coronary Intervention / Q000379:methods* / Q000401:mortality; D000072657:ST Elevation Myocardial Infarction; D016896:Treatment Outcome; D014481:United States