Outcomes and temporal trends of inpatient percutaneous coronary intervention at centers with and without on-site cardiac surgery in the United States

IMPORTANCE: There are concerns whether percutaneous coronary intervention (PCI) at centers without on-site cardiac surgery is safe outside of a tightly regulated research environment. OBJECTIVE: To analyze the outcomes and temporal trends of inpatient PCI at centers without on-site cardiac surgery in an unselected and nationally representative population of the United States. DESIGN, SETTING, AND PARTICIPANTS: A national inpatient sample (N = 6 912 232) was used to identify patients who underwent inpatient PCI in the United States from January 1, 2003, to December 31, 2012. Hospitals that performed 1 or more coronary artery bypass graft surgeries in a given calendar year were classified as centers with on-site cardiac surgery, and weighted sampling of all inpatient hospitalizations was performed. Data analysis was performed from February to May 2016. EXPOSURES: Inpatient PCI. MAIN OUTCOMES AND MEASURES: In-hospital mortality. RESULTS: Of the 6 912 232 inpatient PCIs performed, 2 336 334 patients (33.8%) were women and 4 575 898 (66.2%) were men; their mean (SD) age was 64.5 (12.3) years. Of these PCIs, 396 741 (5.7%) were conducted at centers without on-site cardiac surgery. The rate of in-hospital mortality was significantly lower at centers with on-site cardiac surgery compared with centers without on-site cardiac surgery (1.4% vs 1.9%; unadjusted odds ratio [OR], 0.74; 95% CI, 0.72-0.75). After adjustment, there was no significant difference in in-hospital mortality between centers with and without on-site cardiac surgery (OR, 1.01; 95% CI, 0.98-1.03; P = .62) for acute coronary syndromes and elective procedures requiring inpatient hospitalization. In addition, there were no significant differences in the risk-adjusted, in-hospital mortality between the 2 groups in prespecified subgroups after adjusting for multiple comparisons, including ST-elevation myocardial infarction (OR, 0.99; 95% CI, 0.96-1.03; P = .65), non-ST-elevation acute coronary syndrome (OR, 0.99; 95% CI, 0.93-1.05; P = .66), and elective PCI (OR, 0.93; 95% CI, 0.84-1.03; P = .17). There was a significant increase in the proportion of PCIs at centers without on-site cardiac surgery within the study period (from 1.8% to 12.7%; P < .001 for trend by Cochrane-Armitage test) reflected across all the indications. CONCLUSIONS AND RELEVANCE: There was a 7-fold increase in the proportion of PCIs at centers without on-site cardiac surgery from 2003 to 2012 in the United States, with the adjusted in-hospital mortality after inpatient PCI being similar at centers with and without on-site cardiac surgery. These data provide evidence that PCI at centers without on-site cardiac surgery may be safe in the modern era.