Safety-net hospitals compete in PCI mortality, bleeding, kidney injury

Although safety-net hospitals (SNHs) provide care for greater proportions of uninsured patients, in-hospital mortality rates related to percutaneous coronary interventions (PCIs) are only slightly higher than at other hospitals.

Also, according to a study published online in the Journal of the American College of Cardiology, risk-adjusted rates for acute kidney injury and bleeding related to PCI in SNHs were comparable to rates in other hospitals.

“Underinsurance is a risk factor for poor PCI-associated outcomes,” wrote lead author Tushar Archarya, MD, the University of California, San Francisco, and colleagues. “Because SNHs treat greater numbers of uninsured patients, it is important to evaluate how their outcomes differ from non-SNHs.”

Regional studies have found higher PCI-associated mortality in underinsured patients, the authors stated. However, whether the higher mortality rates resulted from the patients’ own risk factors or were attributable to the care at SNHs remained unclear. Underinsured patients generally have reduced access to outpatient care, more cardiovascular risk factors and a higher likelihood of presenting at a hospital during an acute medical emergency.

SNHs are likelier than others to be low-volume, rural hospitals. Compared to other hospitals, they treat more patients of color and more patients who use tobacco.

To facilitate comparisons between hospitals, the American College of Cardiology’s National Cardiovascular Data Registry (NCDR) has created risk models for periprocedural outcomes after PCI. The study’s authors state, though, that those models may not factor in the features of the patients treated at SNHs.

“Comparing the risk-adjusted outcomes of SNHs and non-SNHs can provide important insights into the validity of NCDR risk models in comparing different types of hospitals,” they wrote.

The research team analyzed data on 3,746,961 patients, which were collected between 2009 and 2015 by the NCDR CathPCI Registry. 

“After adjusting for patients’ characteristics using the NCDR risk model, patients treated at SNHs had higher risk-adjusted in-hospital mortality,” the researcher wrote. The increase was four additional deaths per 1,000 cases of PCI. However, the risk-adjusted bleeding rate and acute kidney injury rate of SNH patients were similar to patients at non-SNHs. 

Volume seemed to play a part in the observed differences in mortality rates.

“Lower PCU volume of SNHs (365 vs. 538 PCIs per year) could also be a contributor to the excess mortality,” the authors wrote, adding that higher-volume SNHs may actually be performing at par with non-SNHs.

Authors concluded in-hospital mortality rates of patients admitted for PCI at SNHs were only slightly higher than at other hospitals and there were no differences in acute kidney injury rates and bleeding rates.