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Original Investigation |

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

Xin Zheng, MD, PhD1; Jeptha P. Curtis, MD2,3; Shuang Hu, PhD1; Yongfei Wang, MS2; Yuejin Yang, MD, PhD4; Frederick A. Masoudi, MD, MSPH5; John A. Spertus, MD, MPH6; Xi Li, MD, PhD1; Jing Li, MD, PhD1; Kumar Dharmarajan, MD, MBA2,3; Nicholas S. Downing, MD2; Harlan M. Krumholz, MD, SM2,3,7,8; Lixin Jiang, MD, PhD1 ; for the China PEACE Collaborative Group
[+] Author Affiliations
1National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
2Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
3Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
4Division of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
5Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
6Department of Cardiovascular Outcomes Research, Saint Luke’s Mid America Heart Institute/University of Missouri–Kansas City
7Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
8Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
JAMA Intern Med. 2016;176(4):512-521. doi:10.1001/jamainternmed.2016.0166.
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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.

Figures in this Article

Figures

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Figure 1.
Trends in Hospital Admissions and Percutaneous Coronary Intervention (PCI) Indication

A, Hospital admissions for coronary artery catheterization and PCI (P < .001). B, Proportion of PCI procedures for stable coronary artery disease (CAD) (P < .001), unstable angina (P < .001), ST-segment elevation myocardial infarction (STEMI) (P < .001), and non-STEMI (NSTEMI) (P < .001) among all the PCI procedures. C, Trends in the proportion of primary PCI (P = .51), PCI after fibrinolytic therapy (P < .001), and late reperfusion for patients who did not receive fibrinolytic therapy or primary PCI during the same admission (P < .001) among all the PCI procedures for patients with STEMI.

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Figure 2.
Trends in Percutaneous Coronary Intervention (PCI) Quality Metrics

A, Proportion of primary PCI procedures with recording of hospital arrival time (P = .10) and balloon dilation time (P = .86). B, Proportion of documentation of PCI with missing procedural success indicators (P = .03) and successful procedures among PCIs with complete documentation of success indicators (P < .001). C, Proportion of PCI procedures with serum creatinine levels assessed before (P < .001) and after (P < .001) PCI, and cardiac biomarkers assessed after PCI (P = .64) (for the first PCI procedure if more than 1 procedure was performed during a hospitalization), as well as procedures with documentation of contrast volume (P < .001). D, Proportion of patients with missing discharge medications (P = .13) and documentation of statin (P < .001), aspirin (P < .001), and thienopyridine (clopidogrel or ticlopidine) use (P < .001) among patients with stents.

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Figure 3.
Unadjusted Rate and Adjusted Odds Ratios (ORs) of Adverse Outcomes in Patients Undergoing Percutaneous Coronary Intervention

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

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