Novel Goalpost for PCI Excellence Is Borrowed From the Surgeons

Researchers made a case for failure to rescue (FTR) as a potential quality metric in percutaneous coronary intervention (PCI), using records from a large nationwide registry.

Although PCI is considered a safe procedure for the most part — with overall in-hospital mortality reaching just 1.3% from April 2018 to June 2021 — the 3.5% of patients who had at least one PCI complication wound up dying in-hospital in 19.7% of cases, based on the American College of Cardiology National Cardiovascular Data Registry’s CathPCI Registry.

FTR was subject to significant hospital-level variation: between two patients treated at two randomly selected hospitals who have an intraprocedural complication during PCI, one would be 48% more likely to die than the other just because of the difference in setting, according to researchers led by Jacob Doll, MD, of VA Puget Sound Health Care System in Seattle, reporting in Circulation: Cardiovascular Interventions.

FTR is already established as a quality metric in multiple specialties including adult cardiac surgery, trauma care, and gynecological surgery.

The appeal of this non-traditional metric in cardiology is that it may overcome some limitations of existing quality measures. Procedural complication and mortality rates, for example, are known to depend in part on patient characteristics that can’t be helped by good PCI.

FTR is thought to more closely align with actual hospital characteristics and quality.

“FTR demonstrated only a modest correlation with hospital-level complication rate and unadjusted in-hospital mortality, indicating that FTR may measure a different domain of care and therefore provide complementary value,” Doll and colleagues reported based on their analysis.

“Hospitals with high FTR should examine their complication management processes, including early recognition of patient deterioration, operator and staff competencies, and postprocedural acute care teams,” they urged.

Ajay Kirtane, MD, SM, and two colleagues of Columbia University Irving Medical Center/New York-Presbyterian Hospital in New York City, called FTR a “useful initial step for case review and the further identification of remediable change.”

“However, a patient’s journey post-procedure is complex, and nonprocedural-related factors contributing to mortality need to be recognized. Hence, we should not overreact to any individual FTR but rather use this metric as an indicator in striving to achieve excellent patient outcomes,” Kirtane and colleagues wrote in an accompanying editorial.

After all, mortality is simply “unavoidable in some cases,” Doll and colleagues cautioned. “Many patients will die from causes unrelated to the PCI procedure or despite heroic efforts from the cardiovascular team. Therefore, a collaborative and nonjudgmental approach to FTR is advised. Blaming an individual or team would likely inhibit quality improvement efforts.”

For the time being, Kirtane and colleagues stressed avoidance of PCI complications in the first place and prompt recognition and management of complications that do occur.

Not to be neglected, either, is the postprocedural period requiring good multidisciplinary care with adequate resources, communication, and early recognition of need for care escalation, the editorialists added.

Doll’s team conducted a retrospective study that included over 2 million adults who had PCI procedures logged in the CathPCI Registry. The PCI procedures took place at 1,483 hospitals.

People considered to have major complications were those with records of significant coronary dissection, coronary artery perforation, vascular complication, significant bleeding within 48 hours, new cardiogenic shock, and tamponade during the procedure. These PCI complications stayed stable during the study period (from 3.6% to 3.4%), but FTR rose from 17.1% to 20.1% (P<0.001).

The strongest predictor of FTR was frailty, followed by other patient factors such as diabetes, chronic hemodialysis, cardiomyopathy, multivessel disease, and severe calcifications.

The investigators acknowledged that patient frailty had been assessed by retrospective chart extraction, however, and therefore possibly biased.

Additionally, given the limited hospital-level variables collected in the registry, Doll and colleagues said they were unable to identify any hospital characteristics associated with FTR. They also could not account for an artificially low FTR at hospitals that frequently transfer out their sickest patients.

“Our data provide evidence of feasibility and between-hospital variation, but important questions remain regarding the implementation of FTR in practice,” according to Doll’s group. “These include the optimal composite measure of PCI complications, whether to exclude high-risk patients, how to benchmark hospitals, and how FTR will be integrated into existing quality improvement programs.”

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