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David E. Wennberg, MD, MPH; F. Lee Lucas, PhD; Andrea E. Siewers, MPH; Merle A. Kellett, MD; David J. Malenka, MD

JAMA. 2004;292:1961-1968.

Context  An ongoing debate focuses on whether institutions should perform percutaneous coronary interventions (PCIs) without an onsite coronary artery bypass graft (CABG) surgery program.

Objective  To compare patient outcomes following PCI at US institutions performing this procedure without and with onsite cardiac surgery.

Design, Setting, and Patients  Medicare hospital (part A) data were used to identify PCIs performed on fee-for-service Medicare enrollees (n = 625 854) aged at least 65 years at acute care facilities between January 1, 1999, and December 1, 2001. Hospitals without and with onsite cardiac surgery were identified based on the presence of claims for CABG surgery. Patients were characterized as undergoing primary/rescue PCI, defined as an emergency procedure performed on the same day of admission for an acute myocardial infarction (MI), vs all other PCIs.

Main Outcome Measures  Post-PCI CABG surgery and combined in-hospital and 30-day mortality.

Results  A total of 178 hospitals performed PCIs without onsite cardiac surgery and 943 hospitals performed PCIs with onsite cardiac surgery. Patients undergoing PCIs in hospitals without onsite cardiac surgery were similar to those with onsite cardiac surgery with respect to age, sex, race, and measurable comorbidities; however, patients undergoing PCIs in hospitals without onsite cardiac surgery were more likely to have a primary/rescue PCI (22.0% vs 5.6%, P < .001). Patients undergoing PCIs in hospitals without cardiac surgery were more likely to die (6.0% vs 3.3%; adjusted odds ratio [OR], 1.29; 95% confidence interval [CI], 1.14-1.47; P < .001). After accounting for baseline differences, mortality for patients with primary/rescue PCI was similar in institutions without and with cardiac surgery (adjusted OR, 0.93; 95% CI, 0.80-1.08; P = .34). However, for the larger non-primary/rescue PCI population, mortality was higher in hospitals without onsite cardiac surgery (adjusted OR, 1.38; 95% CI, 1.14-1.67; P=.001). This increase in mortality was primarily confined to hospitals performing 50 or less Medicare PCIs per year.

Conclusions  Percutaneous coronary interventions in hospitals without onsite cardiac surgery are often performed for reasons other than immediate treatment of an MI and are associated with a higher risk of adverse outcomes. Policies aimed at increasing access to primary/rescue PCI through promoting PCI in hospitals without cardiac surgery may inadvertently lead to an overall increase in mortality related to PCI.

Author Affiliations: Center for Outcomes Research and Evaluation (Drs Wennberg and Lucas, and Ms Siewers) and Department of Medicine, Maine Medical Center, Portland (Dr Kellett); Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH (Drs Wennberg and Malenka); and Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Dr Malenka).

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