Coronary Catheterization and Percutaneous Coronary Intervention in China: 10-Year Results From the China PEACE-Retrospective CathPCI Study

Abstract

Importance: The use of coronary catheterization and percutaneous coronary intervention (PCI) is increasing in China, but, to date, there are no nationally representative assessments of the quality of care and outcomes in patients undergoing these procedures.

Objective: To assess the quality of care and outcomes of patients undergoing coronary catheterization and PCI in China.

Design, setting, and participants: In a clinical observational study (China PEACE [Patient-Centered Evaluative Assessment of Cardiac Events]-Retrospective CathPCI Study), we used a 2-stage, random sampling strategy to create a nationally representative sample of 11 241 patients undergoing coronary catheterization and PCI at 55 urban Chinese hospitals in calendar years 2001, 2006, and 2011. Data analysis was performed from July 11, 2014, to November 20, 2015.

Main outcomes and measures: Patient characteristics, treatment patterns, quality of care, and outcomes associated with these procedures and changes over time.

Results: Of the 11 241 patients included in the study, the samples included, for 2001, 285 women (weighted percentage, 28.6%); for 2006, 826 women (weighted percentage, 32.2%), and for 2011, 2588 women (weighted percentage, 35.7%). Mean (SD) ages were 58 (8), 60 (11), and 61 (11) years, respectively. Between 2001 and 2011, estimated national rates of hospitalizations for coronary catheterization increased from 26 570 to 452 784 and for PCI, from 9678 to 208 954 (17-fold and 21-fold), respectively. More than half of stable patients undergoing coronary catheterization had nonobstructive coronary artery disease; this amount did not change significantly over time (2001: 60.3% [95% CI, 56.1%-64.5%]; 2011: 57.5% [95% CI, 55.8%-59.3%], P = .05 for trend). The proportion of PCI procedures performed via radial approach increased from 3.5% (95% CI, 1.7%-5.3%) in 2001 to 79.0% (95% CI, 77.7%-80.3%) in 2011 (P < . 001 for trend). The use of drug-eluting stents (DESs) increased from 18.0% (95% CI, 14.2%-21.7%) in 2001 to 97.3% (95% CI, 96.9%-97.7%) in 2011 (P < .001 for trend) largely owing to increased use of domestic DESs. The median length of stay decreased from 14 days (interquartile range [IQR], 9-20) in 2001 to 10 days (IQR, 7-14) in 2011 (P < .001 for trend). In-hospital mortality did not change significantly, but both adjusted risk of any bleeding (odds ratio [OR], 0.53 [95% CI, 0.36-0.79], P < .001 for trend) and access bleeding (OR, 0.23 [95% CI, 0.12-0.43], P < .001) were decreased between 2001 and 2011. The medical records lacked documentation needed to calculate commonly used process metrics including door to balloon times for primary PCI and the prescription of evidence-based medications at discharge.

Conclusions and relevance: Although the use of catheterization and PCI in China has increased dramatically, we identified critical quality and documentation gaps that represent opportunities to improve care. Our findings can serve as a foundation to guide future quality improvement initiatives in China.

Figure 1. Hospital Admissions and PCI indication

(A) Trends in hospital admissions for coronary catheterization and PCI (P_trend< .001); (B) Trends in the proportion of PCI procedures for stable CAD (P_trend< .001), UA (P_trend< .001), NSTEMI (P_trend< .001) and STEMI (P_trend= .004) among all the PCI procedures; (C) Trends in the proportion of primary PCI (P_trend= .07), PCI after fibrinolytic therapy (P_trend< .001) and late reperfusion ^a(P_trend<.001) among all the PCI procedures for patients with STEMI. CAD: coronary artery disease; NSTEMI: non ST- segment elevation myocardial infarction; PCI: percutaneous coronary intervention; STEMI: ST-segment elevation myocardial infarction; UA: unstable angina. ^a For patients who didn’t receive fibrinolytic therapy or primary PCI during the same admission.

Figure 2. PCI Quality Metrics

^aTrends in the proportion of primary PCI procedures with recording hospital arrival time (P_trend= .10); ^b Trends in the proportion of primary PCI procedures with recording balloon dilation time (P_trend= .86); ^c Trends in the proportion of PCI with missing procedural success indicators (P_trend=.03); ^d Trends in the proportion of successful procedures among PCIs with complete documentation of success indicators (P_trend< .001); ^e Trends in the proportion of PCI procedures with creatine assessed pre PCI (P_trend< .001)^{*; f} Trends in the proportion of procedures with creatine assessed post PCI (P_trend< .001)^{*; g} Trends in the proportion of procedures with cardiac biomarkers assessed post-PCI (P_trend= .64)^{*; h} Trends in the proportion of procedures with documentation of contrast volume (P_trend< .001); ⁱ Trends in the proportion of patients with missing all discharge medications(P_trend= .13); ^j Trends in the proportion of patients with documentation of statin (P_trend< .001);^k Trends in the proportion of patients with documentation of aspirin (P_trend< .001);^l Trends in the proportion of patients with documentation of thienopyridine (clopidogrel or ticlopidine) (P_trend< .001) ^#. PCI: percutaneous coronary intervention. ^* : For the first PCI procedure if more than one procedure during a hospitalization. ^# : Among patients with stents.

Figure 3. Unadjusted Rate and Adjusted Odds Ratio of Adverse Outcomes of Patients Undergoing PCI

Adjusted odds ratio (OR) of patient outcomes are shown along the horizontal axis with the vertical line demarking an OR of 1 (i.e., no difference from year 2001); estimates to the right (i.e., >1) are associated with higher risk of the outcome, while those to the left (i.e., <1) indicate lower risk of the outcome. The variables for risk adjustment include cardiogenic shock, STEMI versus non STEMI, eGFR, gender, and age. C= 0.77 for death, C= 0.76 for death or treatment withdrawal, C= 0.70 for composite complications, C= 0.64 for any bleeding, C= 0.63 for major bleeding, C= 0.69 for access bleeding, and C= 0.71 for blood transfusion. Composite endpoints: death or withdrawal, stroke or repeat target vessel revascularization. eGFR: estimated glomerular filtration rate; STEMI: ST-segment elevation myocardial infarction.