Outcomes of PCI in Relation to Procedural Characteristics and Operator Volumes in the United States

Abstract

Background Professional guidelines have reduced the recommended minimum number to an average of 50 PCI procedures performed annually by each operator. Operator volume patterns and associated outcomes since this change are unknown. Objectives To describe PCI operator procedure volumes; characteristics of low-, intermediate-, and high-volume operators; and the relationship between operator volume and clinical outcomes in a large, contemporary, nationwide sample Methods Using data from the nationally representative NCDR CathPCI registry collected between July 1, 2009 and March 31, 2015, we examined operator annual PCI volume. We divided operators into low- (< 50 PCIs/year), intermediate- (50–100 PCIs/year), and high-volume (> 100 PCIs/year) groups, and determined the adjusted association between annual PCI volume and in-hospital outcomes, including mortality. Results The median number of annual procedures performed per operator was 59 (25th, 75th percentiles: 21, 106); 44% of operators performed < 50 PCI procedures/year. Low-volume operators more frequently performed emergency and primary PCI procedures and practiced at hospitals with lower annual PCI volumes. Unadjusted in-hospital mortality was 1.86% for low-volume operators, 1.73% for intermediate-volume operators, and 1.53% for high-volume operators. The adjusted risk of in-hospital mortality was higher for PCI procedures performed by low- and intermediate-volume operators compared with those performed by high-volume operators (adjusted OR 1.16, 95% CI 1.12–1.21 for low vs. high; adjusted OR 1.05, 95% CI 1.02–1.09 for intermediate vs. high volume) as was the risk for new dialysis post PCI. No volume relationship was seen for post-PCI bleeding. Conclusions Many PCI operators in the U.S. are performing fewer than the recommended number of PCI procedures annually. Though absolute risk differences are small and may be partially explained by unmeasured differences in case mix between operators, there remains an inverse relationship between PCI operator volume and in-hospital mortality that persisted in risk-adjusted analyses.

In hospital outcomes of primary percutaneous intervention in patients presenting with acute myocardial infarction in Saudi Arabia – A single center study

“…We think this is probably due to low comfort level of operators to adopt this approach in high risk patients another reason is being a low volume center (17). Angiographic success was achieved in 97% similar to recent trends of success.…”

“Should SCAI update its position on the role of Public Reporting?”

“…At the hospital system level, the Certificate of Need (CON) process, largely put in place as a part of the Health Planning Resources Development Act of 1974, is tasked with regulating the institution of new cardiac catheterization laboratories and arguably validates the continued existence of those in place based on procedural volume and unmet needs within each community. However, CON requirements and processes are enacted at the state level and large degrees of variation exist, which is reflected in the marked differences in average PCI operator volumes by state . This may also be an opportunity for reevaluation and standardization.…”

Volume brings value

“…In a single center, left main PCI study by Xu et al, high‐volume operators (defined as annual left main PCI cases ≥ 15) had better clinical outcomes with lower rates of cardiac death. Indeed, a recent report from the U.S. based National Cardiovascular Data Registry by Fanaroff et al eluted on the association of low volume operators (<50 PCIs annually), which compose the vast majority in the U.S. healthcare system (44%) with patient's clinical outcomes suggesting that mortality rates were highest in this subgroup reaching 1.86% as opposed to intermediate‐ (27%) and high‐volume subgroups (29%). Although the ACC/AHA/SCAI guidelines suggest that metrics such as 50 PCIs annually averaged over 2‐years performed in an institution that does >200 PCI procedures/year suffice for clinical competency, there are various arguments related to the procedural cut‐off raised by leading centers from Asia where PCI in high‐risk patients with very complex lesions are being frequently performed.…”