Safety-Net Hospitals Don’t Lag Behind in Terms of Early PCI Outcomes
In-hospital outcomes were largely similar regardless of patient mix, but whether differences might emerge long-term is unknown.
So-called safety-net hospitals are often thought to be hindered by a lack of resources and more difficult cases and thus to achieve less positive outcomes than hospitals that treat higher-income patients who have health insurance. However, new study results suggest otherwise, showing similar results for PCI patients no matter whether their hospital is “safety net” or not.
Lower-income, underinsured, and uninsured patients pose unique problems for hospitals, because they tend to miss more of their follow-up visits and have uncontrolled comorbidities. But as this report shows, when it comes to PCI, these patients only have subtly higher rates of mortality compared with those treated elsewhere.
Patients who end up being treated at safety-net hospitals “tend to get less medical care” in general, Theodore A. Bass, MD (University of Florida College of Medicine-Jacksonville), who wrote the paper’s accompanying editorial, told TCTMD. “Comorbid conditions such as hypertension, diabetes, or other comorbidities are often untreated or less well treated; and they have access to really limited medical care. So it’s important that the medical care that they have access to has solid quality outcomes.”
As senior author John Ambrose, MD (University of California-San Francisco, Fresno, CA), said in a press release: “[T]he fact that these hospitals are able to keep mortality rates low and achieve these outcomes when performing PCI—nearly matching non-safety-net hospitals—is quite remarkable.”
The study, published online today in the JACC: Cardiovascular Interventions, builds upon previous research reports that have found underinsured and uninsured PCI patients are often more likely to have much higher mortality rates.
PCI Outcomes at Safety-Net Hospitals
Lead author Tushar Acharya, MD (University of California-San Francisco), and colleagues analyzed over 3.5 million patients enrolled in the National Cardiovascular Data Registry CathPCI Registry between 2009 and 2015. In total, there were 282 safety-net and 1,134 non-safety-net hospitals. The safety-net hospitals tended to have smaller patient volumes and to be located in rural communities in the southern part of the United States.
The demographics of patients being treated at safety-net hospitals were as follows: their average age was 63 years old, 17% were not white, 33% were smokers, and 48% were admitted via the emergency department (ED). Fully 20% presented with STEMI.
On the other hand, patients at non-safety-net hospitals had significantly different characteristics. On average they were 65 years old, 12% were not white, 26% were smokers, and 38% came into the facility through the ED. Among this patient population group, the STEMI rate was 14% (P < 0.001 for all comparisons vs patients at safety-net hospitals).
For patients getting PCI at safety-net facilities, the relative likelihood of dying in-hospital was significantly higher (OR 1.23; 95% CI 1.17-1.32). But in terms of the absolute difference, the disparity between the safety-net and non-safety-net groups only amounted to 0.4%. And in the same vein, the odds of bleeding (OR 1.05; 95% CI 1.00-1.12) and acute kidney injury (OR 1.01; 95% CI 0.96-1.07) were nearly identical.
Complex Patients, Quality Medical Care
Bass noted that safety-net hospitals generally have challenges with funding their cath labs, having consistent access to high-cost medications, and dealing with high-risk patients. All of these factors might contribute to procedural risk in terms of kidney failure or renal failure, but the study didn’t find that, Bass further explained.
Ambrose told TCTMD that his fellow cardiologists should be proud of what they’ve achieved at safety-net hospitals. “I think we have done quite well in treating the uninsured,” he expounded.
I think we have done quite well in treating the uninsured. John Ambrose
In the end, Acharya and colleagues say that in spite of caring for large groups of undertreated patient populations, safety-net hospitals “are able to achieve satisfactory if not similar outcomes as [other facilities].” Looking ahead, it’s not yet known whether insurance affects long-term outcomes in these cases, they say. “Whether obtaining health insurance will lead to better healthcare access and translate into improvement of outcomes including procedural mortality remains unclear and requires further study.”
Bass concludes in his editorial that the “study helps shed more light on the potential issues of healthcare disparity in cardiovascular interventional care in the United States.
“Although the lack of any strong signal suggesting inferior care is not a surprise, it is important to appreciate the great heterogeneity of [safety-net hospitals] in the current healthcare system to better understand and best address quality of care issues,” he continues. “It may well be that, not only are PCI outcomes noninferior at [safety-net hospitals] compared with [elsewhere], the sicker more complicated patient with more comorbidities might perhaps be better served at [safety-net hospitals].”
Acharya TA, Salisbury AC, Spertus JA, et al. In-hospital outcomes of percutaneous coronary intervention in America’s safety net: insights from the NCDR Cath-PCI Registry. J Am Coll Cardiol Intv. 2017;10:1475-1485.
Bass T. The challenges involving assessing percutaneous coronary intervention outcomes in safety-net hospitals. J Am Coll Cardiol Intv. 2017;10:1486-1488.
- Bass and Ambrose report no relevant conflicts of interest.