Afternoon PCI procedures linked to poor outcomes
MedWire News: Non-urgent percutaneous coronary intervention (PCI) procedures performed after noon on working days are associated with higher procedural failure and death rates than those performed in the morning, Canadian research suggests.
Reporting the findings in the American Heart Journal, William Ghali (University of Calgary) and colleagues cite increasing operator fatigue and differences in process of care as possible explanations for the association.
They write: “Operator fatigue may be higher toward the end of a long working day. Fatigue among health care workers has been reported to be associated with medical errors.”
The team analyzed the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry for the outcomes of 2492 patients undergoing non-urgent PCI procedures during weekday working hours (7 am to 6 pm) from 1999 to 2004 in Alberta, Canada.
Patients were grouped according to procedure time; morning procedure group (7.00 am to 12.00 pm, n=1446) and afternoon procedure group (12.01 pm to 6.00 pm, n=1037). Death and procedure failure (defined as target vessel revascularization [TVR]) rates were measured at 7 days, 30 days, and 1 year post procedure.
Results showed that patients undergoing PCI in the afternoon had higher rates of TVR compared with morning patients at 7 days (0.6% vs 0.1%, p=0.07) and 30 days (1.5% vs 0.7%, p=0.04).
Similarly, the primary endpoint of absolute death or TVR occurred more frequently at both 7 and 30 days among afternoon than morning PCI patients, at 0.9% versus 0.3% and 2.0% versus 1.0%, respectively (both p=0.04).
And the rate of death at 1 year was 2.2% in afternoon patients compared with 1.1% in morning patients (p=0.03).
In multivariate analysis, however, the increased risk for death or TVR in the afternoon-PCI patients was not statistically significant.
Of note, the group who underwent procedures after noon had more advanced left ventricular dysfunction, heart failure, and severe angina than the morning-procedure group, and the researchers say that “differences in baseline patient characteristics likely account for at least some of the differences in outcomes observed.”
But they add that adjusted odds ratios were very similar to crude odds ratios, “suggesting that these factors do not completely account for the observed differences in event rates.”
The researchers conclude: “Further study is required to confirm these findings and determine whether patient characteristics, operator fatigue, differences in process of care, or a combination of these factors accounts for the difference in outcomes.”
MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010
By Lauretta Ihonor