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Operator Volume and Long-Term Outcomes After PCI
Study Questions:
What is the association between operator percutaneous coronary intervention (PCI) volume and 1-year outcomes, including all-cause death, hospitalization for myocardial infarction (MI), or unplanned coronary revascularization?
Methods:
The investigators used the National Cardiovascular Data Registry (NCDR) CathPCI registry data linked with Medicare claims data, and examined the association between operator PCI volume and long-term outcomes among patients aged ≥65 years. Operators were stratified by average annual PCI volume (counting PCIs performed in patients of all ages): low- (<50 PCIs), intermediate- (50-100), and high-volume operators (>100). One-year unadjusted rates of death and major adverse coronary events (MACE, defined as death, readmission for MI, or unplanned coronary revascularization) were calculated using Kaplan-Meier methods. The proportional hazards assumption was not met and risk-adjusted associations between operator volume and outcomes were calculated separately from the time of PCI to hospital discharge and from hospital discharge to 1-year follow-up.
Results:
Between July 1, 2009 and December 31, 2014, 723,644 PCI procedures were performed by 8,936 operators: 2,553 high-, 2,878 intermediate-, and 3,505 low-volume. Compared with high- and intermediate-volume operators, low-volume operators more often performed emergency PCI and their patients had fewer cardiovascular comorbidities. Over 1 year of follow-up, 15.9% of patients treated by low-volume operators had a MACE event compared with 16.9% of patients treated by high-volume operators (p = 0.004). After multivariable adjustment, intermediate- and high-volume operators had a significantly lower rate of in-hospital death than low-volume operators (odds ratio [OR] 0.91, 95% confidence interval [CI] 0.86-0.96 for intermediate vs. low; OR 0.79, 95% CI 0.75-0.83 for high vs. low). There were no significant differences in rates of MACE, death, MI, or unplanned revascularization between operator cohorts from hospital discharge to 1 year of follow-up (adjusted hazard ratio [HR] for MACE: 0.99, 95% CI 0.96-1.01 for intermediate vs. low; HR 1.01, 95% CI 0.99-1.04 for high vs. low).
Conclusions:
The authors concluded that after risk adjustment, higher operator volume was associated with lower in-hospital mortality, but no difference in post-discharge MACE including mortality.
Perspective:
This study reports that operators performing fewer than 50 PCIs annually had a higher risk-adjusted rate of in-hospital mortality, but did not have a higher risk-adjusted hazard of death or MACE over 1-year post-discharge follow-up than higher volume operators. Overall, these results are reassuring that the small inverse association between operator volume and short-term outcomes does not carry over to long-term outcomes. Furthermore, given that the association between operator volumes and in-hospital mortality is small and operator volume is not associated with long-term outcomes, clinical practice guidelines as well as credentialing and certification organizations should consider volume standards in the context of overall care quality, and should not emphasize operator volume as a quality metric or certification requirement.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and ACS
Keywords: Acute Coronary Syndrome, CathPCI Registry, Hospital Mortality, Medicare, Myocardial Infarction, Morbidity, Myocardial Ischemia, Myocardial Revascularization, National Cardiovascular Data Registries, Outcome Assessment, Health Care, Percutaneous Coronary Intervention, Quality of Health Care, Secondary Prevention
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