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Problem Statement or Scientific Question: Public reporting of risk-adjusted mortality for patients treated with percutaneous coronary intervention (PCI) is often used as a measure of overall quality of cardiovascular care. We sought to decrease in-hospital mortality rates for PCI patients within a large health care system that included 3 PCI-capable hospitals.

Background/Project Intent: While prior studies have demonstrated a low (< 1%) mortality rate for elective PCI, emergent PCI for patients with acute myocardial infarction is associated with a higher (< 5%) incidence of in-hospital death. Patients with ST-Segment Elevation Myocardial Infarction (STEMI), including those with out-of-hospital Cardiac arrest (OHCA) and cardiogenic shock, represent the highest risk PCI patient subgroups. STEMI mortality is directly correlated with treatment times to re-canalize an occluded coronary vessel. Patients with OHCA often will undergo a successful PCI, but may expire at a later time because of irreversible anoxic brain damage. Cardiogenic shock patients nationally remain as a high-risk subgroup with average 40-50% mortality despite the use of appropriate pharmacotherapy and mechanical circulatory support.

Methodology: As a large health care system located in central Connecticut and consisting of 3 PCI-capable and 4 non-PCI, transferring hospitals, we undertook a multi-specialty, multi-disciplinary, and system-wide approach to decreasing PCI mortality. All PCI outcomes have been continually monitored from data obtained from the ACC NCDR PCI and AHA Get-With-The-Guidelines CAD Registries. Specific quality improvement measures which have been instituted include: 1. Formation of a System-Wide Acute Coronary Syndrome (ACS) Council: The ACS Council was initially established in 2016 and consists of key stakeholders from across the entire health system (e.g., cardiac catheterization (CCL), emergency ward (EW), clinical cardiology, administrative personnel). This council has met quarterly over the last 7 years to apply the most up-to-date evidenced-based treatment guidelines and standardized care across the system. ACS Council operations have involved a comprehensive redesign of all aspects of STEMI care including patient registration, rapid EW diagnosis, CCL pre-hospital pre-activation and bypass of the EW when appropriate, and CCL operations. Attempts to improve treatment time for transfer STEMI patients have involved education for all transferring non-PCI hospitals on how to reduce “Door In-Door Out” time and alternative use of thrombolytic agents, as well as organization of all EMS services to use pre-activation and diversion directly to a PCI capable hospital. Each hospital within the system also formed a “local” region-specific ACS Council that worked on specific regional needs, but all efforts were coordinated and rolled up to the system-wide council. Each “local” ACS Councils at the non-PCI capable hospitals examine and access their performance to improve their outcomes. Data is provided on request to each transferring hospital, and each EMS agency receives reports on every STEMI patient that is transferred. 2. Formation of a High-Risk Percutaneous Coronary Intervention (CHIP) Program: The CHIP program was formally established in 2018 and consists of a multidisciplinary (cardiac catheterization, cardiac surgery, advanced heart failure, clinical cardiology, anesthesia) team that meets as needed to make recommendations on the choice of optimal revascularization strategies for high-risk patients with complex coronary artery disease. Choice of PCI, coronary bypass surgery or medical therapy is made by the team following careful consideration patient comorbidities, disease acuity, non-invasive and invasive testing results, societal guidelines, appropriate use criteria, risk stratification tools, and patient wishes/expectations. 3. Participation in the Cardiac Arrest to Enhance Survival (CARES) Registry: Since 2018, our health care system has joined the CARES registry and also formulated a multidisciplinary OHCA work group. Using comprehensive CARES data, this work group has provided continual updates on OHCA treatment and outcomes and provided system-wide recommendations on the appropriate triage of OHCA patients for emergent cardiac catheterization and possible PCI, as well as appropriate use of hypothermia. 4. Establishment of System Wide Recommendations For Treatment of Cardiogenic Shock Efforts to improve PCI outcomes in patients with cardiogenic shock have focused on the integration of appropriate treatment guidelines, including establishment of an algorithm outlining the appropriate use of mechanical circulatory support (e.g., IABP, Impella, ECMO) as well as appropriate pharmacotherapy. 5. Establishment of Structured Reporting in the Cardiac Catheterization Laboratory Beginning in 2021, we have instituted structured reporting for all cardiac catheterization procedures including PCI. This has resulted in more accurate and real-time capture of patient and procedural characteristics with improved capture of patient comorbidities to improve national registry risk stratification.

Results: Since 2021 Q3, NCDR PCI in-hospital risk standardized mortality progressively decreased for all three PCI patient subgroups. By 2022 Q4, mortality rates at 2 of our 3 hospitals were in the top 10% of all participating hospitals. 48- PCI in-hospital risk standardiized mortality (all patients) R4Q 2021Q3: Hospital A 2.15 Hospital B 2.16 Hospital C 2.57 2022Q4: Hospital A 1.43 Hospital B 1.54 Hospital C 1.88

Value Proposition: Improving PCI complication rates remains as a significant quality improvement opportunity for all health care systems to decrease patient morbidity and mortality and decrease health care costs.

Conclusions: Using national registry data to drive quality improvement that integrate evidence-based care and best practices, we have instituted system wide changes to decrease PCI mortality, particularly in patients with STEMI, OHCA and cardiogenic shock. There efforts have resulted in a steady decline in PCI in-hospital mortality at all 3 of our PCI capable hospitals within our health care system.

References: 1. Chang KY, Chiu N, Aggarwal R. In-Hospital Mortality for Inpatient Percutaneous Coronary Interventions in the United States. Am J Cardiol. 2021 Nov 15;159:30-35. 2. Castro-Dominguez YS, Wang Y, Minges KE, McNamara RL, Spertus JA, Dehmer GJ, Messenger JC, Lavin K, Anderson C, Blankinship K, Mercado N, Clary JM, Osborne AD, Curtis JP, Cavender MA. Predicting In-Hospital Mortality in Patients Undergoing Percutaneous Coronary Intervention. J Am Coll Cardiol. 2021 Jul 20;78(3):216-229. 3. Menees DS, Peterson ED, Wang Y, Curtis JP, Messenger JC, Rumsfeld JS, Gurm HS. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med. 2013 Sep 5;369(10):901-9. 4. Wadhera RK, Joynt Maddox KE, Yeh RW, Bhatt DL. Public Reporting of Percutaneous Coronary Intervention Outcomes: Moving Beyond the Status Quo. JAMA Cardiol. 2018 Jul 1;3(7):635-640.

Problem Statement or Scientific Question: Public reporting of risk-adjusted mortality for patients treated with percutaneous coronary intervention (PCI) is often used as a measure of overall quality of cardiovascular care. We sought to decrease in-hospital mortality rates for PCI patients within a large health care system that included 3 PCI-capable hospitals.

Background/Project Intent: While prior studies have demonstrated a low (< 1%) mortality rate for elective PCI, emergent PCI for patients with acute myocardial infarction is associated with a higher (< 5%) incidence of in-hospital death. Patients with ST-Segment Elevation Myocardial Infarction (STEMI), including those with out-of-hospital Cardiac arrest (OHCA) and cardiogenic shock, represent the highest risk PCI patient subgroups. STEMI mortality is directly correlated with treatment times to re-canalize an occluded coronary vessel. Patients with OHCA often will undergo a successful PCI, but may expire at a later time because of irreversible anoxic brain damage. Cardiogenic shock patients nationally remain as a high-risk subgroup with average 40-50% mortality despite the use of appropriate pharmacotherapy and mechanical circulatory support.

Methodology: As a large health care system located in central Connecticut and consisting of 3 PCI-capable and 4 non-PCI, transferring hospitals, we undertook a multi-specialty, multi-disciplinary, and system-wide approach to decreasing PCI mortality. All PCI outcomes have been continually monitored from data obtained from the ACC NCDR PCI and AHA Get-With-The-Guidelines CAD Registries. Specific quality improvement measures which have been instituted include: 1. Formation of a System-Wide Acute Coronary Syndrome (ACS) Council: The ACS Council was initially established in 2016 and consists of key stakeholders from across the entire health system (e.g., cardiac catheterization (CCL), emergency ward (EW), clinical cardiology, administrative personnel). This council has met quarterly over the last 7 years to apply the most up-to-date evidenced-based treatment guidelines and standardized care across the system. ACS Council operations have involved a comprehensive redesign of all aspects of STEMI care including patient registration, rapid EW diagnosis, CCL pre-hospital pre-activation and bypass of the EW when appropriate, and CCL operations. Attempts to improve treatment time for transfer STEMI patients have involved education for all transferring non-PCI hospitals on how to reduce “Door In-Door Out” time and alternative use of thrombolytic agents, as well as organization of all EMS services to use pre-activation and diversion directly to a PCI capable hospital. Each hospital within the system also formed a “local” region-specific ACS Council that worked on specific regional needs, but all efforts were coordinated and rolled up to the system-wide council. Each “local” ACS Councils at the non-PCI capable hospitals examine and access their performance to improve their outcomes. Data is provided on request to each transferring hospital, and each EMS agency receives reports on every STEMI patient that is transferred. 2. Formation of a High-Risk Percutaneous Coronary Intervention (CHIP) Program: The CHIP program was formally established in 2018 and consists of a multidisciplinary (cardiac catheterization, cardiac surgery, advanced heart failure, clinical cardiology, anesthesia) team that meets as needed to make recommendations on the choice of optimal revascularization strategies for high-risk patients with complex coronary artery disease. Choice of PCI, coronary bypass surgery or medical therapy is made by the team following careful consideration patient comorbidities, disease acuity, non-invasive and invasive testing results, societal guidelines, appropriate use criteria, risk stratification tools, and patient wishes/expectations. 3. Participation in the Cardiac Arrest to Enhance Survival (CARES) Registry: Since 2018, our health care system has joined the CARES registry and also formulated a multidisciplinary OHCA work group. Using comprehensive CARES data, this work group has provided continual updates on OHCA treatment and outcomes and provided system-wide recommendations on the appropriate triage of OHCA patients for emergent cardiac catheterization and possible PCI, as well as appropriate use of hypothermia. 4. Establishment of System Wide Recommendations For Treatment of Cardiogenic Shock Efforts to improve PCI outcomes in patients with cardiogenic shock have focused on the integration of appropriate treatment guidelines, including establishment of an algorithm outlining the appropriate use of mechanical circulatory support (e.g., IABP, Impella, ECMO) as well as appropriate pharmacotherapy. 5. Establishment of Structured Reporting in the Cardiac Catheterization Laboratory Beginning in 2021, we have instituted structured reporting for all cardiac catheterization procedures including PCI. This has resulted in more accurate and real-time capture of patient and procedural characteristics with improved capture of patient comorbidities to improve national registry risk stratification.

Results: Since 2021 Q3, NCDR PCI in-hospital risk standardized mortality progressively decreased for all three PCI patient subgroups. By 2022 Q4, mortality rates at 2 of our 3 hospitals were in the top 10% of all participating hospitals. 48- PCI in-hospital risk standardiized mortality (all patients) R4Q 2021Q3: Hospital A 2.15 Hospital B 2.16 Hospital C 2.57 2022Q4: Hospital A 1.43 Hospital B 1.54 Hospital C 1.88

Value Proposition: Improving PCI complication rates remains as a significant quality improvement opportunity for all health care systems to decrease patient morbidity and mortality and decrease health care costs.

Conclusions: Using national registry data to drive quality improvement that integrate evidence-based care and best practices, we have instituted system wide changes to decrease PCI mortality, particularly in patients with STEMI, OHCA and cardiogenic shock. There efforts have resulted in a steady decline in PCI in-hospital mortality at all 3 of our PCI capable hospitals within our health care system.

References: 1. Chang KY, Chiu N, Aggarwal R. In-Hospital Mortality for Inpatient Percutaneous Coronary Interventions in the United States. Am J Cardiol. 2021 Nov 15;159:30-35. 2. Castro-Dominguez YS, Wang Y, Minges KE, McNamara RL, Spertus JA, Dehmer GJ, Messenger JC, Lavin K, Anderson C, Blankinship K, Mercado N, Clary JM, Osborne AD, Curtis JP, Cavender MA. Predicting In-Hospital Mortality in Patients Undergoing Percutaneous Coronary Intervention. J Am Coll Cardiol. 2021 Jul 20;78(3):216-229. 3. Menees DS, Peterson ED, Wang Y, Curtis JP, Messenger JC, Rumsfeld JS, Gurm HS. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med. 2013 Sep 5;369(10):901-9. 4. Wadhera RK, Joynt Maddox KE, Yeh RW, Bhatt DL. Public Reporting of Percutaneous Coronary Intervention Outcomes: Moving Beyond the Status Quo. JAMA Cardiol. 2018 Jul 1;3(7):635-640.

Decreasing PCI Mortality in a Large Health Care System
Dominick Mariconda
Dominick Mariconda
Affiliations:
null
American College of Cardiology Quality Summit. Mariconda D. 10/11/2023; 400287; 2519359
user
Dominick Mariconda
Affiliations:
null
Problem Statement or Scientific Question: Public reporting of risk-adjusted mortality for patients treated with percutaneous coronary intervention (PCI) is often used as a measure of overall quality of cardiovascular care. We sought to decrease in-hospital mortality rates for PCI patients within a large health care system that included 3 PCI-capable hospitals.

Background/Project Intent: While prior studies have demonstrated a low (< 1%) mortality rate for elective PCI, emergent PCI for patients with acute myocardial infarction is associated with a higher (< 5%) incidence of in-hospital death. Patients with ST-Segment Elevation Myocardial Infarction (STEMI), including those with out-of-hospital Cardiac arrest (OHCA) and cardiogenic shock, represent the highest risk PCI patient subgroups. STEMI mortality is directly correlated with treatment times to re-canalize an occluded coronary vessel. Patients with OHCA often will undergo a successful PCI, but may expire at a later time because of irreversible anoxic brain damage. Cardiogenic shock patients nationally remain as a high-risk subgroup with average 40-50% mortality despite the use of appropriate pharmacotherapy and mechanical circulatory support.

Methodology: As a large health care system located in central Connecticut and consisting of 3 PCI-capable and 4 non-PCI, transferring hospitals, we undertook a multi-specialty, multi-disciplinary, and system-wide approach to decreasing PCI mortality. All PCI outcomes have been continually monitored from data obtained from the ACC NCDR PCI and AHA Get-With-The-Guidelines CAD Registries. Specific quality improvement measures which have been instituted include: 1. Formation of a System-Wide Acute Coronary Syndrome (ACS) Council: The ACS Council was initially established in 2016 and consists of key stakeholders from across the entire health system (e.g., cardiac catheterization (CCL), emergency ward (EW), clinical cardiology, administrative personnel). This council has met quarterly over the last 7 years to apply the most up-to-date evidenced-based treatment guidelines and standardized care across the system. ACS Council operations have involved a comprehensive redesign of all aspects of STEMI care including patient registration, rapid EW diagnosis, CCL pre-hospital pre-activation and bypass of the EW when appropriate, and CCL operations. Attempts to improve treatment time for transfer STEMI patients have involved education for all transferring non-PCI hospitals on how to reduce “Door In-Door Out” time and alternative use of thrombolytic agents, as well as organization of all EMS services to use pre-activation and diversion directly to a PCI capable hospital. Each hospital within the system also formed a “local” region-specific ACS Council that worked on specific regional needs, but all efforts were coordinated and rolled up to the system-wide council. Each “local” ACS Councils at the non-PCI capable hospitals examine and access their performance to improve their outcomes. Data is provided on request to each transferring hospital, and each EMS agency receives reports on every STEMI patient that is transferred. 2. Formation of a High-Risk Percutaneous Coronary Intervention (CHIP) Program: The CHIP program was formally established in 2018 and consists of a multidisciplinary (cardiac catheterization, cardiac surgery, advanced heart failure, clinical cardiology, anesthesia) team that meets as needed to make recommendations on the choice of optimal revascularization strategies for high-risk patients with complex coronary artery disease. Choice of PCI, coronary bypass surgery or medical therapy is made by the team following careful consideration patient comorbidities, disease acuity, non-invasive and invasive testing results, societal guidelines, appropriate use criteria, risk stratification tools, and patient wishes/expectations. 3. Participation in the Cardiac Arrest to Enhance Survival (CARES) Registry: Since 2018, our health care system has joined the CARES registry and also formulated a multidisciplinary OHCA work group. Using comprehensive CARES data, this work group has provided continual updates on OHCA treatment and outcomes and provided system-wide recommendations on the appropriate triage of OHCA patients for emergent cardiac catheterization and possible PCI, as well as appropriate use of hypothermia. 4. Establishment of System Wide Recommendations For Treatment of Cardiogenic Shock Efforts to improve PCI outcomes in patients with cardiogenic shock have focused on the integration of appropriate treatment guidelines, including establishment of an algorithm outlining the appropriate use of mechanical circulatory support (e.g., IABP, Impella, ECMO) as well as appropriate pharmacotherapy. 5. Establishment of Structured Reporting in the Cardiac Catheterization Laboratory Beginning in 2021, we have instituted structured reporting for all cardiac catheterization procedures including PCI. This has resulted in more accurate and real-time capture of patient and procedural characteristics with improved capture of patient comorbidities to improve national registry risk stratification.

Results: Since 2021 Q3, NCDR PCI in-hospital risk standardized mortality progressively decreased for all three PCI patient subgroups. By 2022 Q4, mortality rates at 2 of our 3 hospitals were in the top 10% of all participating hospitals. 48- PCI in-hospital risk standardiized mortality (all patients) R4Q 2021Q3: Hospital A 2.15 Hospital B 2.16 Hospital C 2.57 2022Q4: Hospital A 1.43 Hospital B 1.54 Hospital C 1.88

Value Proposition: Improving PCI complication rates remains as a significant quality improvement opportunity for all health care systems to decrease patient morbidity and mortality and decrease health care costs.

Conclusions: Using national registry data to drive quality improvement that integrate evidence-based care and best practices, we have instituted system wide changes to decrease PCI mortality, particularly in patients with STEMI, OHCA and cardiogenic shock. There efforts have resulted in a steady decline in PCI in-hospital mortality at all 3 of our PCI capable hospitals within our health care system.

References: 1. Chang KY, Chiu N, Aggarwal R. In-Hospital Mortality for Inpatient Percutaneous Coronary Interventions in the United States. Am J Cardiol. 2021 Nov 15;159:30-35. 2. Castro-Dominguez YS, Wang Y, Minges KE, McNamara RL, Spertus JA, Dehmer GJ, Messenger JC, Lavin K, Anderson C, Blankinship K, Mercado N, Clary JM, Osborne AD, Curtis JP, Cavender MA. Predicting In-Hospital Mortality in Patients Undergoing Percutaneous Coronary Intervention. J Am Coll Cardiol. 2021 Jul 20;78(3):216-229. 3. Menees DS, Peterson ED, Wang Y, Curtis JP, Messenger JC, Rumsfeld JS, Gurm HS. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med. 2013 Sep 5;369(10):901-9. 4. Wadhera RK, Joynt Maddox KE, Yeh RW, Bhatt DL. Public Reporting of Percutaneous Coronary Intervention Outcomes: Moving Beyond the Status Quo. JAMA Cardiol. 2018 Jul 1;3(7):635-640.

Problem Statement or Scientific Question: Public reporting of risk-adjusted mortality for patients treated with percutaneous coronary intervention (PCI) is often used as a measure of overall quality of cardiovascular care. We sought to decrease in-hospital mortality rates for PCI patients within a large health care system that included 3 PCI-capable hospitals.

Background/Project Intent: While prior studies have demonstrated a low (< 1%) mortality rate for elective PCI, emergent PCI for patients with acute myocardial infarction is associated with a higher (< 5%) incidence of in-hospital death. Patients with ST-Segment Elevation Myocardial Infarction (STEMI), including those with out-of-hospital Cardiac arrest (OHCA) and cardiogenic shock, represent the highest risk PCI patient subgroups. STEMI mortality is directly correlated with treatment times to re-canalize an occluded coronary vessel. Patients with OHCA often will undergo a successful PCI, but may expire at a later time because of irreversible anoxic brain damage. Cardiogenic shock patients nationally remain as a high-risk subgroup with average 40-50% mortality despite the use of appropriate pharmacotherapy and mechanical circulatory support.

Methodology: As a large health care system located in central Connecticut and consisting of 3 PCI-capable and 4 non-PCI, transferring hospitals, we undertook a multi-specialty, multi-disciplinary, and system-wide approach to decreasing PCI mortality. All PCI outcomes have been continually monitored from data obtained from the ACC NCDR PCI and AHA Get-With-The-Guidelines CAD Registries. Specific quality improvement measures which have been instituted include: 1. Formation of a System-Wide Acute Coronary Syndrome (ACS) Council: The ACS Council was initially established in 2016 and consists of key stakeholders from across the entire health system (e.g., cardiac catheterization (CCL), emergency ward (EW), clinical cardiology, administrative personnel). This council has met quarterly over the last 7 years to apply the most up-to-date evidenced-based treatment guidelines and standardized care across the system. ACS Council operations have involved a comprehensive redesign of all aspects of STEMI care including patient registration, rapid EW diagnosis, CCL pre-hospital pre-activation and bypass of the EW when appropriate, and CCL operations. Attempts to improve treatment time for transfer STEMI patients have involved education for all transferring non-PCI hospitals on how to reduce “Door In-Door Out” time and alternative use of thrombolytic agents, as well as organization of all EMS services to use pre-activation and diversion directly to a PCI capable hospital. Each hospital within the system also formed a “local” region-specific ACS Council that worked on specific regional needs, but all efforts were coordinated and rolled up to the system-wide council. Each “local” ACS Councils at the non-PCI capable hospitals examine and access their performance to improve their outcomes. Data is provided on request to each transferring hospital, and each EMS agency receives reports on every STEMI patient that is transferred. 2. Formation of a High-Risk Percutaneous Coronary Intervention (CHIP) Program: The CHIP program was formally established in 2018 and consists of a multidisciplinary (cardiac catheterization, cardiac surgery, advanced heart failure, clinical cardiology, anesthesia) team that meets as needed to make recommendations on the choice of optimal revascularization strategies for high-risk patients with complex coronary artery disease. Choice of PCI, coronary bypass surgery or medical therapy is made by the team following careful consideration patient comorbidities, disease acuity, non-invasive and invasive testing results, societal guidelines, appropriate use criteria, risk stratification tools, and patient wishes/expectations. 3. Participation in the Cardiac Arrest to Enhance Survival (CARES) Registry: Since 2018, our health care system has joined the CARES registry and also formulated a multidisciplinary OHCA work group. Using comprehensive CARES data, this work group has provided continual updates on OHCA treatment and outcomes and provided system-wide recommendations on the appropriate triage of OHCA patients for emergent cardiac catheterization and possible PCI, as well as appropriate use of hypothermia. 4. Establishment of System Wide Recommendations For Treatment of Cardiogenic Shock Efforts to improve PCI outcomes in patients with cardiogenic shock have focused on the integration of appropriate treatment guidelines, including establishment of an algorithm outlining the appropriate use of mechanical circulatory support (e.g., IABP, Impella, ECMO) as well as appropriate pharmacotherapy. 5. Establishment of Structured Reporting in the Cardiac Catheterization Laboratory Beginning in 2021, we have instituted structured reporting for all cardiac catheterization procedures including PCI. This has resulted in more accurate and real-time capture of patient and procedural characteristics with improved capture of patient comorbidities to improve national registry risk stratification.

Results: Since 2021 Q3, NCDR PCI in-hospital risk standardized mortality progressively decreased for all three PCI patient subgroups. By 2022 Q4, mortality rates at 2 of our 3 hospitals were in the top 10% of all participating hospitals. 48- PCI in-hospital risk standardiized mortality (all patients) R4Q 2021Q3: Hospital A 2.15 Hospital B 2.16 Hospital C 2.57 2022Q4: Hospital A 1.43 Hospital B 1.54 Hospital C 1.88

Value Proposition: Improving PCI complication rates remains as a significant quality improvement opportunity for all health care systems to decrease patient morbidity and mortality and decrease health care costs.

Conclusions: Using national registry data to drive quality improvement that integrate evidence-based care and best practices, we have instituted system wide changes to decrease PCI mortality, particularly in patients with STEMI, OHCA and cardiogenic shock. There efforts have resulted in a steady decline in PCI in-hospital mortality at all 3 of our PCI capable hospitals within our health care system.

References: 1. Chang KY, Chiu N, Aggarwal R. In-Hospital Mortality for Inpatient Percutaneous Coronary Interventions in the United States. Am J Cardiol. 2021 Nov 15;159:30-35. 2. Castro-Dominguez YS, Wang Y, Minges KE, McNamara RL, Spertus JA, Dehmer GJ, Messenger JC, Lavin K, Anderson C, Blankinship K, Mercado N, Clary JM, Osborne AD, Curtis JP, Cavender MA. Predicting In-Hospital Mortality in Patients Undergoing Percutaneous Coronary Intervention. J Am Coll Cardiol. 2021 Jul 20;78(3):216-229. 3. Menees DS, Peterson ED, Wang Y, Curtis JP, Messenger JC, Rumsfeld JS, Gurm HS. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med. 2013 Sep 5;369(10):901-9. 4. Wadhera RK, Joynt Maddox KE, Yeh RW, Bhatt DL. Public Reporting of Percutaneous Coronary Intervention Outcomes: Moving Beyond the Status Quo. JAMA Cardiol. 2018 Jul 1;3(7):635-640.

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