HA Territory-wide PCI Audit

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1 HA Territory-wide PCI Audit PCI Audit Working Group Central Committee (Cardiac Services) HA Convention 26

2 Percutaneous Coronary Intervention

3 Background HA AP target 2/3, coordinated by PCI Working Group of Central Committee (Cardiac Services) Participants: All HA hospitals via CCLs Mechanism: Prospective Comparative Audit Audit Period: Jan 23 3 Dec 25

4 Objectives Assess baseline characteristics of PCI procedures done in Compare crude/standardized mortality/complication ratio among CCLs in HA hospitals Identify pre-intervention status/co-morbidity/risk factors in relation to post-pci mortality/complications within 72 hours Build a risk-adjusted model for post-pci mortality/complications

5 Audit Tools PHCA s audit form Supplemented by Discharge summary epr consultation note Laboratory results On-site record check (randomly & on cases with major complications) Audit Nurse to ensure quality and completeness of data

6 Baseline Characteristics Baseline Characteristics No No % Renal failure Renal failure CVA CVA Previous PCI Previous PCI Age Age DM DM Smoking history Smoking history HT HT Male sex Male sex Hypercholesterolemia Hypercholesterolemia % No No % No No

7 Case mix Primary (for AMI), 52, 39% Rescue (for AMI), 92, 24% Unplanned redo PCI, 7, 2% Primary (for AMI), 45, 3% Rescue (for AMI), 44, 9% Unplanned redo PCI, 6, % ACS other than AMI, 678, 74% ACS other than AMI, 864, 77% 23 (394 cases) Elective, 2975, 762% Primary (for AMI), 65, 35% Rescue (for AMI), 85, 8% Elective, 3835, 784% 24 (4894 cases) ACS other than AMI, 859, 396% Elective, 2584, 55% 25 (4693 out of 4956 cases signed)

8 Severity of disease >2 vessels attempted, 226, 58% >2 vessels attempted, 377, 77% 2 vessels attempted, 4, 26% 2 vessels attempted, 349, 276% vessel attempted, 2664, 682% vessel attempted, 368, 647% 23 (394 cases) 2 vessels attempted, 37, 279% >2 vessels attempted, 287, 6% 24 (4894 cases) 25 (468 cases) (3 cases are excluded due to missing and invalid value) vessel attempted, 386, 659%

9 Characteristics of the worst lesion Type C, 33, 336% Type A, 48, 23% Type B, 86, 26% Type C, 672, 342% Type A, 44, 9% Type B, 55, 236% Type B2, 34, 334% 23 (394 cases) Type C, 438, 36% Type A, 239, 5% Type B2, 627, 332% Type B, 39, 243% 24 (4894 cases) Type B2, 877, 4% 25 (4693 cases)

10 Angiographic result Angiographic result No No % Total Total Unsuccessful Unsuccessful Partially successful Partially successful Successful Successful % No No % No No

11 Use of PCI devices/drugs #case % #case % #case % Ballon Stent Rotablator DCA Distal Protection Device Thrombectomy Device IABP/CPS Gp 2b3a Inhibitor Closure Device

12 GENERNAL REPORT Total no of PCI cases performed in HA hospitals 3,94 4,894 4,693* 3,49 On-site random checking 5% 2% 2% 2-5% 5% Total mortality ( 72 hours) 23(59%) 3(6%) 3(66%) 84(62%) Major 52(33%) complications reported (excluding death) ( 72 hours ) 95(94%) 8(73%) 228(69%) *signed cases only (signed + unsigned cases = 4,965)

13 Major Complications on event basis in a total of 394, 4894, and 4693 cases for 23 3, 24, and 25 respectively (direct and indirect procedure causes included) World- No % No % No % wide % Death New Non-Q Q MI % New Q-wave Q MI % Unplanned CABG % Unplanned Re-PCI % Stroke 2 4 5% Bleeding % Cardiac Tamponade Vascular Surgery or Repair Up to 3%

14 Complications : Patients with Primary PCI done Major complications No 23 % (n=52)( No 24 % (n=45) No 25 % (n=65 65) Death MI-Non Q 7 MI- Q wave 7 6 Unplanned CABG Unplanned Re-PCI Stroke 2 2 Bleeding with Hb Drop 3g/dl 7 6 Cardiac Tamponade 7 6 Vascular Surgery or Repair

15 Complications: Patients with Cardiogenic Shock Major complications No 23 % (n=( n=57) No 24 % (n=64 64) No 25 % (n=67 67) Death MI-Non Q 6 5 MI- Q wave 8 Unplanned CABG Unplanned Re-PCI 2 3 Stroke 2 3 Bleeding with Hb Drop 3g/dl Cardiac Tamponade Vascular Surgery or Repair

16 Crude and Standardized Mortality/Complication ratio

17 Comparison of crude and standardized Post-PCI PCI mortality ratio,23~ Hospital X Post-PCI mortality ratio 5 5 before adjustment Hospital variation was significantly reduced after case mix adjustment after adjustment Standardized by Intercurrent Cardiogenic Shock and Primary PCI

18 Crude and Standardized Ratio and 95% confidence interval for Post-PCI PCI Mortality (Linear scale),23~5 7 6 After adjusting the case mix, there is 5 no statistical difference between hospital performance against the overall norm Upper limit Lower limit Crude ratio Upper limit Lower limit - A B C D E F G H I J Standardized ratio Hospital

19 Comparison of crude and standardized Post-PCI PCI complication ratio,23~5 4 Hospital 2 X Post-PCI complication ratio before adjustment Hospital variation was reduced after case mix adjustment after adjustment Standardized by Characteristic of worst lesion and No of Major Native Arteries with >=5% lesions

20 Crude and Standardized Ratio and 95% confidence interval for Post-PCI PCI Complications (Linear scale),23~5 25 After adjusting the case mix, 2 there is still statistical difference between hospital performance against the overall norm but the difference has been minimized 5 5 Upper limit Lower limit Crude ratio Upper limit Lower limit A B C D E F G H I J Standardized ratio Hospital

21 Potential risk factors for post-pci death Factor Angina type MI Heart failure VT/VF EF CVA Indications Thrombectomy device IABP/CPS Gp2b3a inhibitors Stress Test showing Reversible Ischemia Age p-value p< p< p< p< p< p= p< p= p< p< p<5 p<5

22 Potential risk factors for complications (exclude death) Factor Angina type Angiographic results Thrombectomy device IABP/CPS Gp2b3a inhibitors Characteristic of worst leison No of major arteries with >=5% leisons Indications p-value p< p< p< p< p< p<5 p<5 p<5

23 Variable excluded in logistic regression model for post- operation mortality within 72 hours In order to maximize the use of death information in our data file, 3 explanatory variables have to be excluded in regression analysis even though they are significant (p<25) in univariate analysis Stress test: 952% of total death cases (8 out of 84) from Not done and Unknown categories Ejection Fraction: 322 cases (237% of total cases)with unknown EF 4 (66% of total post-pci death)of which are of post-pci mortality cases Hypercholesterolemia: 8 death cases come from its unknown category(24% if total post-pci death)

24 Notes for logistic regression model for post-operation operation complication within 72 hours In order to maximize the use of complication information in our data file, 2 explanatory variables have to be excluded in regression analysis even though they are significant (p<25)in univariate analysis Stress test: 733% of total complication cases (54 out of 2) from Not done and Unknown categories Ejection Fraction: 322 cases (237% of total cases) with unknown EF 62 (295% of total post-pci complication) of which are of post-pci complication cases

25 Logistic regression model Logistic regression model ( ) X β X β X β α π π Ln Logit(Y) = = ,) x,x x X, x X interest outcome of Probability( = = = = = = X X X X e e Y β β α β β α π

26 Risk-adjusted (logistic regression) model for post-pci mortality within 72 hours Odds Ratio p-value Unstable Angina 73 Procedures requiring IABP/CPS 58 < Cardiogenic Shock 48 < Hx of CVA 4 < Sustained VT/VF 34 4 Recent MI 7 7 days 3 8 Unsuccessful Angiographic result 3 45 Renal Failure /3 vessel disease 9 345

27 Receiver operating characteristic (ROC) curve Logistic regression model for post-pci mortality within 72 hours Sensitivity The sharper the bend and the closer to the upper left corner, the greater the accuracy of the model A measure of the model s ability to discriminate between those subjects who experience the outcome of interest versus those who do not 2 C statistics=area under the curve= Specificity

28 Risk-adjusted (logistic regression) model for post-pci complications within 72 hours Odds Ratio p-valuep Procedures requiring IABP/CPS 48 < Unsuccessful Angiographic result 39 < Procedures requiring GpIIb/IIIa 35 < inhibitors >2 lesions attempted 2 < Hx of CVA 9 26 Type B2/C lesions 7 74 Female sex 5 3

29 Receiver operating characteristic (ROC) curve Logistic regression model for post-pci complication within 72 hours Sensitivity C statistics=area under the curve= Specificity

30 ACC-NCDR Risk Adjustment Mortality Model Factors asso with increased risk of PCI mortality: Odds ratio Cardiogenic shock 849 Increasing age Emergent salvage 338 Emergent 575 Urgent 78 Decreased LVEF AMI 24 hours 3 DM 4 Renal failure 34 COPD 33

31 Michigan PCI Mortality Prediction Tool

32 Michigan PCI Mortality Prediction Tool

33 Long-term PCI Outcomes no 23 % no 24 % no % no % World- wide % Total no of cases 3,94 4,894 4,693 3,49 72-hour mortality 23 59% 3 6% 3 66% 84 62% 5-4% In-hospital mortality 43 % 5 2% 62 32% 55 5% 9-29% 3-day mortality 45 5% 62 23% 76 62% 83 36% -3%

34 Limitations No data on 6-month 6 redo-pci for Target Lesion Revascularization (TLR) Self-reported cases 23 a full-time audit nurse to check data accuracy 24-5 a part-time time audit nurse 26 onwards data accuracy ensured by individual institutions

35 Way Forward Individual CCLs responsible for data accuracy A designated medical staff as point of contact Half-yearly report feedback to individual CCLs Collaborate with HI & IT Team GRR for PCI reports integrating audit capability (All the CCLs are using the GRR PCI reporting system since January 25) Data Quality cross-check check with data warehouse eg death registry, LIS, MOE Continue HA territory-wide PCI audit to verify the risk-adjusted model Uphold the standard of PCI procedures performed in HA hospitals Interventional Cardiologists more willing to take up high-risk cases Patients more well-informed of the risks of PCI

36 Acknowledgement HK Public Hospital Cardiologists Association HA Central Committee (Cardiac Services) HAHO Statistics and Research Section HAHO HI & IT Team HAHO Clinical Effectiveness Unit

37 Thank you!

06 Validation of risk prediction model

06 Validation of risk prediction model HA Territory-wide PCI Audit 2003-06 06 Validation of risk prediction model PCI Audit Working Group Central Committee (Cardiac Services) HA Convention 2007 Background Participants: All HA hospitals via

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