Utilization of radial artery access for percutaneous coronary intervention for ST-segment elevation myocardial infarction in New York.

OBJECTIVES: This study sought to determine the utilization and outcomes for radial access for percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction (STEMI) in common practice. BACKGROUND: Radial access for PCI has been studied considerably, but mostly in clinical trials. METHODS: All patients undergoing PCI for STEMI in 2009 to 2010 in New York were studied to determine the frequency and the patient-level predictors of radial access. Differences in in-hospital/30-day mortality between radial and femoral access were also studied. RESULTS: Radial access increased from 4.9% in the first quarter of 2009 to 11.9% in the last quarter of 2010. Significant independent predictors were higher body surface area, non-Hispanic ethnicity, Caucasian race, stable hemodynamic state, ejection fraction <30% and ≥50% onset of STEMI from 12 to 23 h before the index procedure, and peripheral vascular disease. Mortality was not related to access site after adjustment for covariates (for radial vs. femoral access, adjusted odds ratio: 0.86, 95% confidence interval: 0.59 to 1.25), but the radial access site was trending toward lower mortality for the 9 hospitals that used it for more than 10% of their patients (adjusted odds ratio: 0.61, 95% confidence interval: 0.36 to 1.02). CONCLUSIONS: The use of a radial access site for PCI in STEMI patients increased between 2009 and 2010, but was still infrequent in 2010, and was used for lower-risk STEMI patients. There was no significant difference in mortality by access site, but there was a trend toward a mortality advantage for patients with a radial access site among hospitals that used it relatively frequently.

The New York State risk score for predicting in-hospital/30-day mortality following percutaneous coronary intervention.

OBJECTIVES: This study sought to develop a percutaneous coronary intervention (PCI) risk score for in-hospital/30-day mortality. BACKGROUND: Risk scores are simplified linear scores that provide clinicians with quick estimates of patients' short-term mortality rates for informed consent and to determine the appropriate intervention. Earlier PCI risk scores were based on in-hospital mortality. However, for PCI, a substantial percentage of patients die within 30 days of the procedure after discharge. METHODS: New York's Percutaneous Coronary Interventions Reporting System was used to develop an in-hospital/30-day logistic regression model for patients undergoing PCI in 2010, and this model was converted into a simple linear risk score that estimates mortality rates. The score was validated by applying it to 2009 New York PCI data. Subsequent analyses evaluated the ability of the score to predict complications and length of stay. RESULTS: A total of 54,223 patients were used to develop the risk score. There are 11 risk factors that make up the score, with risk factor scores ranging from 1 to 9, and the highest total score is 34. The score was validated based on patients undergoing PCI in the previous year, and accurately predicted mortality for all patients as well as patients who recently suffered a myocardial infarction (MI). CONCLUSIONS: The PCI risk score developed here enables clinicians to estimate in-hospital/30-day mortality very quickly and quite accurately. It accurately predicts mortality for patients undergoing PCI in the previous year and for MI patients, and is also moderately related to perioperative complications and length of stay.

The New York risk score for in-hospital and 30-day mortality for coronary artery bypass graft surgery.

BACKGROUND: Simplified risk scores for coronary artery bypass graft surgery are frequently in lieu of more complicated statistical models and are valuable for informed consent and choice of intervention. Previous risk scores have been based on in-hospital mortality, but a substantial number of patients die within 30 days of the procedure. These deaths should also be accounted for, so we have developed a risk score based on in-hospital and 30-day mortality. METHODS: New York's Cardiac Surgery Reporting System was used to develop an in-hospital and 30-day logistic regression model for patients undergoing coronary artery bypass graft surgery in 2009, and this model was converted into a simple linear risk score that provides estimated in-hospital and 30-day mortality rates for different values of the score. The accuracy of the risk score in predicting mortality was tested. This score was also validated by applying it to 2008 New York coronary artery bypass graft data. Subsequent analyses evaluated the ability of the risk score to predict complications and length of stay. RESULTS: The overall in-hospital and 30-day mortality rate for the 10,148 patients in the study was 1.79%. There are seven risk factors comprising the score, with risk factor scores ranging from 1 to 5, and the highest possible total score is 23. The score accurately predicted mortality in 2009 as well as in 2008, and was strongly correlated with complications and length of stay. CONCLUSIONS: The risk score is a simple way of estimating short-term mortality that accurately predicts mortality in the year the model was developed as well as in the previous year. Perioperative complications and length of stay are also well predicted by the risk score.

Predicting trauma inpatient mortality in an administrative database: an investigation of survival risk ratios using New York data.

BACKGROUND: A precise and unbiased measure of injury severity, calculable from administrative data sets, is needed for population-based studies. METHODS: The 2001 Nationwide Inpatient Sample was used to calculate independent and traditional survival risk ratios. Logistic regression models predicting survival for New York State's Statewide Planning and Research Cooperative System 2003 inpatients (117,630 records) were constructed for both types of survival risk ratios. The contribution of only the worst survival risk ratio (SRR), the two worst SRRs, the three worst, the four worst, and all trauma diagnoses was investigated. The contribution of gender and age to the models was assessed. RESULTS: Use of the two worst SRRs, gender, and age gives the best prediction of inhospital mortality. CONCLUSION: Inhospital mortality in both trauma centers and in community hospitals can be predicted well from an administrative database by using three predictors--gender, age, and the product of the SRRs for the two diagnoses with the lowest chance of survival.

Physiologic trauma triage criteria in adult trauma patients: are they effective in saving lives by transporting patients to trauma centers?

BACKGROUND: Trauma triage criteria have been in place for many years and were updated in 1999 by the American College of Surgeons. We are unaware of any studies that have directly examined the ability of these criteria to reduce short-term mortality by transporting patients to trauma centers rather than to noncenters. STUDY DESIGN: Retrospective observational cohort study of adult patients meeting physiologic triage criteria who were transported to 9 regional (Level I) trauma centers, 21 area (Level II) trauma centers, and 119 noncenters in New York in 1996 to 1998. For each triage criterion and for one or more of the criteria, odds ratios and their confidence intervals for mortality in regional and area trauma centers versus noncenters and odds ratios and their confidence intervals for mortality in regional centers versus area centers and noncenters were used to measure performance. RESULTS: Patients in regional trauma centers had considerably lower mortality than patients in area trauma centers and noncenters for two individual triage criteria and for patients with one or more triage criteria (odds ratio, 0.75; 95% CI, 0.63-0.90 for one or more criteria). Also, patients with head injuries who were treated in regional centers had notably lower mortality than patients in other hospitals (odds ratio, 0.67; 95% CI, 0.53-0.85). CONCLUSIONS: In New York, regional trauma centers exhibit considerably lower mortality than area trauma centers or noncenters for adult patients meeting specific physiologic triage criteria. It is important that population-based trauma systems with data from centers and noncenters be developed for the purpose of evaluating and redesigning trauma systems.

A comparison among the abilities of various injury severity measures to predict mortality with and without accompanying physiologic information.

BACKGROUND: A few recent studies have compared the abilities of different injury severity measures to predict inpatient mortality. This study extended previous studies in that it used a registry with noncenters as well as centers, and examined the relative marginal abilities of competing severity measures to predict mortality when physiologic data also are available. METHODS: Several methods for assessing injury severity of trauma patients were compared in terms of their ability to predict mortality with and without the addition of additional demographic and physiologic information using logistic regression models. Separate determinations also were made for all patients and for three groups of patients with blunt trauma resulting from motor vehicle crashes, low falls, and other blunt injuries. Statistical models were compared using measures of discrimination and calibration. RESULTS: The International Classification of Disease-Based Severity Score (ICISS) had the best discrimination for each of the eight models examined, and it was significantly better than all the other measures in relation to the models for all patients and for victims of motor vehicle crashes. The ICISS also had the best calibration in half of the models with and half without demographic and physiologic information. The New Injury Severity Score had the best calibration in relation to two of the remaining four models. Physiologic data add substantially to the ability to predict mortality regardless of the anatomic injury severity measure used. CONCLUSIONS: On the average, the ICISS had the best discrimination of all of the measures, as well as a slight edge with respect to calibration in predicting trauma mortality with or without the aid of demographic or physiologic measures.

Elderly trauma inpatients in New York state: 1994-1998.

BACKGROUND: The aging of the population in the United States has led to an increase in geriatric trauma. This study aimed to examine the characteristics and outcomes of geriatric trauma patients in New York State. METHODS: Four groups of elderly trauma patients (ages 40-64, 65-74, 75-84, and 85+ years) were contrasted with younger adults ages 13 to 39 years with respect to mechanism of injury, discharge disposition, hospital length of stay, comorbidities, and type of hospital in which they were treated. Also, the independent association of each group with in-hospital mortality was investigated for patients with blunt injuries using logistic regression. RESULTS: There was a 17.6% increase between 1994 and 1998 in the number of traumatic injuries qualifying for the New York State Trauma Registry in the 75- to 84-year-old group and a 16.4% increase in the group ages 85 years or older, despite a decrease in traumatic injuries in other age groups. The majority of these injuries among the patients 75 years of age or older resulted from low falls (from the same level). The mortality rate rose substantially with age, from 5.1% to 5.9% to 9.4% to 12.3% to 15.8%, respectively, for the groups ages 13 to 39, 40 to 64, 65 to 74, 75 to 84, and 85 or more years. Also, fewer than 20% of the patients older than 75 years died within 1 day after admission to the hospital, as compared with 44% of the patients younger than 65 years. The groups ages 40 to 64, 65 to 74, 75 to 84, and 85 years or older were all independent (increasingly) significant predictors of mortality for all three mechanisms of injury investigated. The adjusted odds ratios for mortality relative to patients who were 13 to 39 years of age were 2.67, 8.41, 17.40, and 34.98, respectively, for the groups ages 40 to 64, 65 to 74, 75 to 84, and 85 years or older. CONCLUSIONS: Trauma is a serious and escalating problem for the elderly, and increasing age is a significant risk factor for patient mortality.

Severity of injury and mortality associated with pediatric blunt injuries: hospitals with pediatric intensive care units versus other hospitals.

OBJECTIVE: To a) compare in-hospital mortality rates for pediatric (age <13 yrs) patients with blunt injuries in the New York State Trauma Registry based on hospital type (dedicated pediatric intensive care unit [PICU] and designated trauma centers and noncenters that do not have a dedicated PICU) for the purpose of determining whether there is a reduction in mortality at a specialty hospital and b) determine the extent to which high-risk patients are admitted to specialty hospitals. DATA SOURCE: Inpatient data for the years 1994-1998 in the New York State Trauma Registry. STUDY SELECTION: A total of 8,180 pediatric inpatients who suffered blunt injury were selected to examine where patients were treated (PICU, regional trauma center without PICU, area trauma center without PICU, or noncenter without PICU) as a function of injury severity. DATA EXTRACTION: Data were extracted for inpatients aged <13 yrs who suffered blunt injury. DATA SYNTHESIS: The injury severity of inpatients treated at PICUs and regional centers without PICUs was significantly higher than at other hospitals. Risk factors that were independently related to survival of pediatric trauma inpatients were age <5 yrs, motor component of one to five, abnormal systolic blood pressure relative to age, and International Classification of Disease, Ninth Revision-Based Injury Severity Score. Of the total 136 deaths, 133 were among the patients <5 yrs old, motor score <6, and age-related abnormal systolic blood pressure. A total of 66.8% of these patients were treated at PICUs, and 9.9% were treated at regional centers without PICUs. No statistically significant differences in risk-adjusted mortality rates were found by hospital type, but rates at PICUs were lower than for other types of hospitals except for noncenters without PICUs, whose patients were considerably less severely injured. CONCLUSIONS: There is significant triaging of the most seriously injured pediatric trauma inpatients to PICUs, and there is evidence that this policy is effective.