Relationship of Clinical Volume to Performance Measure Adherence for CAD, HF, and AF

Study Questions:

Is there an association between high clinical volume and improved outcomes for outpatients with coronary artery disease (CAD), heart failure (HF), and atrial fibrillation (AF)?


Using the PINNACLE Registry (2009–2012), average monthly provider and practice volumes were calculated for CAD, HF, and AF. Adherence with four American Heart Association CAD, two HF, and one AF performance measure was assessed at the most recent encounter for each patient. Logistic regression models were used to assess the relationship between provider and practice volume and performance on eligible quality measures.


Data incorporated patients from 1,094 providers at 71 practices (practice level analyses n = 654,535; provider level analyses n = 529,938). Median monthly provider volumes were 79 (interquartile range [IQR], 51–117) for CAD, 27 (16–45) for HF, and 37 (24–54) for AF. Median monthly practice volumes were 923 (IQR, 476–1,455) for CAD, 311 (145–657) for HF, and 459 (185–720) for AF. Overall, 55% of patients met all CAD measures, 72% met all HF measures, and 58% met the AF measure. There was no definite relationship between practice volume and concordance for CAD, AF, or HF (p = 0.56, 0.52, and 0.79, respectively). In contrast, higher provider volume was associated with increased concordance for CAD and AF performance measures (p < 0.001 for both), but not for HF (p = 0.36).


In the PINNACLE registry, performance was modest and variable. Higher provider volume was positively associated with quality, whereas practice volume was not.


Compliance with evidence-based treatment is a reasonable way to assess the relationship between physician and practice volume and outcome if the objective is not outcomes. But the application of the data to practice quality measures is limited. It is important to realize that overall ‘compliance’ was only in the mid 50% for CAD and AF, and 72% for CHF. Experienced physicians may decide to stop beta-blockers when there is no ‘clear indication.’ And the role and participation of nonphysician providers working in consort with the billing physicians may have a major impact on compliance with guidelines that is not measurable.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Coronary Artery Disease, Heart Failure, Outcome Assessment (Health Care), National Cardiovascular Data Registries, PINNACLE Registry, Primary Prevention

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