Institutions that did employ a greater number of strategies demonstrated superior outcomes . hospitals , but little is known about what processes or organizational structures impact 30-day readmissions . Karl E . Minges , PhD , MPH , Yale-New Haven Hospital , and colleagues sought to determine hospital strategies independently and significantly associated with lower RSRR . They surveyed 500 hospitals ( 81 % response rate ) participating in the CathPCI Registry .
They performed weighted multivariate regression using CathPCI Registry data to determine the association between specific hospital strategies and hospital 30-day RSRR . They found 5 hospital strategies significantly associated with lower RSRRs , including :
1 ) Review of CathPCI Registry data by cardiology leadership ( seen in 65.8 % of surveyed sites ; p = 0.003 );
2 ) Regular meetings with cardiac rehabilitation to review the care of cardiac patients ( 44 %; p = 0.016 );
3 ) Ability to retain high quality staff ( 64.8 %; p = 0.023 );
4 ) Rapid adoption of new technologies used for PCI ( 75.1 %; p = 0.012 ); and
5 ) Discharge with the date and time of a follow-up appointment already arranged ( 58.3 %; p = 0.003 ).
Hospitals varied in terms of numbers of strategies employed and , despite the effectiveness of these strategies , only a minority of hospitals used all five approaches . However , institutions that did employ a greater number of strategies demonstrated superior outcomes .
Impact of Bleeding Avoidance Strategies Periprocedural bleeding is among the most common complications following PCI and is associated with increased risk for short- and long-term mortality , stroke , longer hospital stay , and higher cost . Multiple bleeding avoidance strategies have been developed to reduce the incidence of bleeding , but which ones work ?
Unlike the Yale study above looking at strategies that reduce 30-day readmission rates , this study of CathPCI data had less promising results .
In data presented at ACC . 16 and published subsequently in JACC Interventions , Vora and colleagues from DCRI analyzed records from almost 2.5 million procedures at 1,358 sites between 2009 and 2013 . In conducting their analysis , they adjusted for patient risk , including variables such as gender , age , body mass index , the presence of cerebrovascular disease , prior PCI , and diabetes .
The detected substantial variation in bleeding rates , despite the fact that bleeding avoidance strategies use was high ( median hospital rate of any such strategy was 86.6 %). Importantly , patient mix explained just one-fifth of the overall hospital level variation in bleeding .
After adjusting for individual patient risk for bleeding , hospital rates for bleeding varied from 2.6 % to 9.3 %. With bleeding avoidance strategies having only a small effect on overall hospital-level
variation , about 70 % of the variation among hospitals remains unexplained .
They did show that when hospitals used bleeding avoidance strategies in more than 85 % of patients , bleeding rates were lower .
Amit N . Vora , MD , MPH , the study ’ s lead author and a cardiologist with the Duke Clinical Research Institute in Durham , NC , addressed limitations associated with using post-procedure bleeding as a performance measure for hospitals . Because such a high percentage of bleeding rates remain unexplained , he said , “ The stringent use of bleeding rate measures to determine reimbursement rates or to penalize institutions by payers and regulators may be premature at this time .”
He and his colleagues did show that higher use of bleeding avoidance strategies was associated with reduced levels of bleeding at the hospital level . That means that efforts to broaden the use of these strategies in all patients might be a reasonable way to reduce overall variation in hospital bleeding rates . Bleeding avoidance strategies were more commonly used in lower risk patients and lower volume hospitals . The analysis showed a 5.85 % reduction with bivalirudin anticoagulation and a 0.88 % reduction with the use of a vascular closure device . In an accompanying editorial comment , Eric Bates , MD , University of Michigan Medical Center , Ann Arbor , MI , noted that the big surprise in this report was that radial artery access had almost no impact on bleeding variation ( a 1.26 % reduction in variation in bleeding rates with transradial access ). In an earlier patient-level analysis from the same registry , Dr . Bates noted that there was a reported significant absolute reduction ( 8.0 % for women , 4.1 % for men ) in bleeding risk with radial artery access .
Dr . Bates noted , “ U . S . interventionalists have been criticized for being slow to adopt radial artery access . And yet , the radialists need to avoid hubris and prove to the skeptics that they are not wearing the emperor ’ s new clothes when they promote the superiority of radial artery access over femoral artery access for all patients .”
Importantly , he added , the study by Vora et al . does not support the use of bleeding rate as a hospital-level PCI performance measure .
The Vora paper and editorial comment are both in the April 25th issue of JACC Interventions . You can find the main paper and the Bates comment by scanning the code .
Fire and Ice Current guidelines recommend ( Class I , level A ) catheter ablation with pulmonary-vein isolation ( PVI ) as treatment for drug-refractory paroxysmal atrial fibrillation ( AF ). Two approaches are widely marketed : radiofrequency ablation ( RFA ) using electroanatomical mapping ( THERMOCOOL , Biosense Webster , Inc .) and cryoballoon ablation using fluoroscopic guidance ( Arctic Front , Medtronic , Inc .). The FIRE AND ICE trial was a multicenter , randomized effort comparing RFA PVI to cryobal-
26 CardioSource WorldNews : Interventions May / June 2016