Impact of Annual Operator and Institutional Volume on Percutaneous Coronary Intervention Outcomes

Badheka, Apurva; Patel, Nileshkumar; Grover, Peeyush; Singh, Vikas; Patel, Nilay; Arora, Shilpkumar; Chothani, Ankit; Mehta, Kathan; Deshmukh, Abhishek; Savani, Ghanshyambhai T.; Patel, Achint; Panaich, Sidakpal; Shah, Neeraj; Rathod, Ankit; Brown, Michael A.; Mohamad, Tamam; Tamburrino, Frank; Kar, Saibal; Makkar, Raj; O’Neill, William W.; Marchena, Eduardo de; Schreiber, Theodore; Grines, Cindy L.; Rihal, Charanjit S.; Cohen, Mauricio G.

doi:10.1161/circulationaha.114.009281

Cited by 152 publications

(96 citation statements)

References 45 publications

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“…[15][16][17][18] A more recent summary of the evidence by a joint task force from the American College of Cardiology Foundation, American Heart Association, and American College of Physicians acknowledged that the large-scale studies in this area have produced heterogeneous findings. 19 Specifically in relation to primary PCI cohorts, a review by the National Clinical Guidance Centre 20 likewise noted that the evidence base is currently insufficient to establish a definitive understanding of the volume-outcome relationship.…”

Section: See Editorial By Kumbhani and Bittlmentioning

confidence: 99%

Total Center Percutaneous Coronary Intervention Volume and 30-Day Mortality

O’Neill

Nicholas

Gale

et al. 2017

Circ: Cardiovascular Quality and Outcomes

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T he relationship between procedural volume and patient outcomes is an important consideration in the provision of percutaneous coronary intervention (PCI). Studies that have suggested the existence of a relationship have informed international guidelines 1-3 on the minimum procedural limits recommended for annual center volume to ensure safe and effective patient care. This is also reflected in recent UK guidance on the provision of PCI. 4 For acute myocardial infarction, the establishment of high-throughput, high-volume heart attack centers within networks of acute cardiac care has been promoted as a factor contributing to the decline in cardiovascular mortality in developed healthcare systems. [5][6][7][8][9] Such centers often also have high volumes of elective PCI and in much of the published literature compare favorably with lower volume centers where higher rates of adverse outcomes, longer lengths of hospital stay, and increased costs have been observed. 10,11 These findings have been reflected in the reconfiguration of UK PCI services over the past decade, specifically the expectation that lower volume units undertake at least 400 procedures per annum. See Editorial by Kumbhani and BittlIt is timely and of international importance to review the evidence for and against a relationship between PCI center volume and clinical outcomes in the UK healthcare system. Such a national review contributes to the assessment of the Background-The relationship between procedural volume and prognosis after percutaneous coronary intervention (PCI) remains uncertain, with some studies finding in favor of an inverse association and some against. This UK study provides a contemporary reassessment in one of the few countries in the world with a nationally representative PCI registry. Methods and Results-A nationwide cohort study was performed using the national British Cardiovascular Intervention Society registry. All adult patients undergoing PCI in 93 English and Welsh NHS hospitals between 2007 and 2013 were analyzed using hierarchical modeling with adjustment for patient risk. Of 427 467 procedures (22.0% primary PCI) in 93 hospitals, 30-day mortality was 1.9% (4.8% primary PCI). 87.1% of centers undertook between 200 and 2000 procedures annually. Case mix varied with center volume. In centers with 200 to 399 PCI cases per year, a smaller proportion were PCI for ST-segment-elevation myocardial infarction (8.4%) than in centers with 1500 to 1999 PCI cases per year (24.2%), but proportionally more were for ST-segment-elevation myocardial infarction with cardiogenic shock (8.4% versus 4.3%). For the overall PCI cohort, after risk adjustment, there was no significant evidence of worse, or better, outcomes in lower volume centers from our own study, or in combination with results from other studies. For primary PCI, there was also no evidence for increased or decreased mortality in lower volume centers. Conclusions-After adjustment for differences in case mix and clinical presentation, this study supports the conclusion o...

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Section: See Editorial By Kumbhani and Bittlmentioning

confidence: 99%

Total Center Percutaneous Coronary Intervention Volume and 30-Day Mortality

O’Neill

Nicholas

Gale

et al. 2017

Circ: Cardiovascular Quality and Outcomes

View full text Add to dashboard Cite

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“…Patients treated by high‐volume operators and at high‐volume centers have been shown to experience a higher rate of procedural success and lower rates of mortality and postprocedural complications 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11. As a consequence, standards of assistance have been recommended for PCI operators 1, 2, 6.…”

Section: Discussionmentioning

confidence: 99%

“…Although patient‐related factors are known to play a key role for those occurrences, it is currently unknown to which degree these adverse events may be also operator dependent. Overall number of procedures performed and the operator experience may affect outcomes of patients undergoing PCI, but this evidence is mainly based on observational studies 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11. Randomized, controlled trials have played a major role in informing the community on the incidence, predictors, and implications of PCI‐related adverse events.…”

mentioning

confidence: 99%

Stent and Dual Antiplatelet Therapy Duration Comparisons in the Setting of a Multicenter Randomized Controlled Trial: Can the Operator Experience Affect the Study Results?

Gargiulo

Heg

Ferrari

et al. 2017

JAHA

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BackgroundOperator experience influences outcomes after percutaneous coronary intervention, but this association in the controlled setting of a randomized, clinical trial is unclear.Methods and ResultsWe investigated operator‐related outcomes (30‐day and 2‐year efficacy and safety end points) among patients undergoing percutaneous coronary intervention and randomized to different dual antiplatelet therapy durations and stent types. A total of 2003 patients were analyzed, and 7 operator groups were compared. The majority of preprocedural and postprocedural characteristics were imbalanced. The primary end point of the study, the composite of death, myocardial infarction, or cerebrovascular accidents, did not differ among operators at 30 days or 2 years. There were no significant differences also for all other individual and composite end points analyzed at 30 days and 2 years, except for 2‐year stent thrombosis (P=0.048) and bleeding events (P=0.022 for Bleeding Academic Research Consortium type 2, 3, or 5). Adjusted comparisons for the main end points showed slight differences among operators at 30 days, but not at 2 years. There was no interaction of operator with dual antiplatelet therapy duration (P=0.112) or stent type (P=0.300). Results remained entirely consistent when operators were stratified by their experience.ConclusionsThere was a weak signal of heterogeneity across study operators for the 30‐day, but not the 2‐year, main study outcomes. No clear effect of operator or operator experience was observed for the comparative efficacy and safety profile of the randomized stent types or dual antiplatelet therapy duration regimens.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00611286.

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“…It is now incumbent upon the operators to know the nuances and subtleties of each of these devices and become facile with their use. With an increase in awareness of learning curve requirements, there have been systematic analyses using large national representative databases to look at optimal case volume needed for CAS, PCI, or PFO closure 10, 11, 12, 13. A 4‐society expert consensus statement published in 2012 details the recommended criteria for existing as well as new TAVR programs, especially pertaining to program and practitioner case volumes 14.…”

Section: Healthcare Provider Aspectsmentioning

confidence: 99%