Total Center Percutaneous Coronary Intervention Volume and 30-Day Mortality

Abstract

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...

Association between operator volume and mortality in primary percutaneous coronary intervention

“…Although evidence suggests institutional PCI volumes are not associated with clinical outcomes,30 our finding that PPCI performed by operators performing <55 PPCI per year is associated with significantly higher probability of 30-day mortality compared with high-volume operators, should prompt re-examination of the AHA recommendation that ≥11 PPCI per year per operator is an acceptable operator volume for the provision of PPCI 20…”

Risk prediction in multicentre studies when there is confounding by cluster or informative cluster size

“…So, the number of teeth within a patient may not be independent of the disease status. In studies investigating the association between the volume of procedures carried out per surgeon, the performance of surgeons performing a specific operation assessed by the proportion of successful operations, may be associated with the number of operations performed [ 22 ].…”

Impact of COVID-19 on primary percutaneous coronary intervention centres in the UK: a survey

“…It should be noted that observational research into the relationship between patient survival outcomes and centre volume in the UK has not found that lower volume centres were putting patients at risk. 1,2…”