Annual Percutaneous Coronary Intervention Research Articles

Current operator volumes of invasive coronary procedures in medicare patients: Implications for future manpower needs in the catheterization laboratory

We seek to assess the per-operator volume of diagnostic catheterizations and percutaneous coronary interventions (PCI) among US cardiologists, and its implication for future manpower needs in the catheterization laboratory. The number of annual Medicare PCIs peaked in 2004 and has trended downward since, however the total number of catheterization laboratories nationwide has increased. It is unknown whether these trends have resulted in a dilution of per-operator volumes, and whether the current supply of interventional cardiologists is appropriate to meet future needs. We analyzed the Centers for Medicare and Medicaid Services 2008 Medicare 5% sample file, and extracted the total number of Medicare fee-for-service (Medicare FFS) diagnostic catheterizations and PCIs performed in 2008. We then determined per-physician procedure volumes using National Provider Identifier numbers. There were 1,198,610 Medicare FFS diagnostic catheterizations performed by 11,029 diagnostic cardiologists, and there were 378,372 Medicare FFS PCIs performed by 6,443 interventional cardiologists in 2008. The data reveal a marked difference in the 2008 distribution of diagnostic catheterizations and PCIs among operators. Just over 10% of diagnostic catheterizations were performed by operators performing 40 or fewer Medicare FFS diagnostic catheterizations, contrasted with almost 30% of PCIs performed by operators with 40 of fewer Medicare FFS PCIs. A significant majority of interventional cardiologists (61%) performed 40 or fewer Medicare FFS PCIs in 2008. There is a high percentage of low-volume operators performing PCI, raising questions regarding annual volume recommendations for procedural skill maintenance, and the future manpower requirements in the catheterization laboratory.

CURRENT OPERATOR VOLUMES OF INVASIVE CORONARY PROCEDURES IN MEDICARE PATIENTS: IMPLICATIONS FOR FUTURE MANPOWER NEEDS IN THE CATHETERIZATION LABORATORY

Objectives We seek to assess the per-operator volume of diagnostic catheterizations and percutaneous coronary interventions (PCI) among US cardiologists, and its implication for future manpower needs in the catheterization laboratory. Background The number of annual Medicare PCIs peaked in 2004 and has trended downward since, however the total number of catheterization laboratories nationwide has increased. It is unknown whether these trends have resulted in a dilution of per-operator volumes, and whether the current supply of interventional cardiologists is appropriate to meet future needs. Methods We analyzed the Centers for Medicare and Medicaid Services 2008 Medicare 5% sample file, and extracted the total number of Medicare fee-for-service (Medicare FFS) diagnostic catheterizations and PCIs performed in 2008. We then determined per-physician procedure volumes using National Provider Identifier numbers. Results There were 1,198,610 Medicare FFS diagnostic catheterizations performed by 11,029 diagnostic cardiologists, and there were 378,372 Medicare FFS PCIs performed by 6,443 interventional cardiologists in 2008. The data reveal a marked difference in the 2008 distribution of diagnostic catheterizations and PCIs among operators. Just over 10% of diagnostic catheterizations were performed by operators performing 40 or fewer Medicare FFS diagnostic catheterizations, contrasted with almost 30% of PCIs performed by operators with 40 of fewer Medicare FFS PCIs. A significant majority of interventional cardiologists (61%) performed 40 or fewer Medicare FFS PCIs in 2008. Conclusions There is a high percentage of low-volume operators performing PCI, raising questions regarding annual volume recommendations for procedural skill maintenance, and the future manpower requirements in the catheterization laboratory.

Abstract P321: Hospital Angioplasty Volumes and ST-Elevation Myocardial Infarction Patient Admission Patterns: Improvement in Florida from 2001-2007

Background: The ACC/AHA guidelines recommend percutaneous coronary intervention (PCI) at high-volume centers with at least 400 procedures per year for ST-elevation myocardial infarction (STEMI), but fewer than 25% of acute care hospitals in the US are PCI capable. In Florida, a statewide system for regional STEMI patient care does not yet exist, but some local STEMI care coalitions have formed. We examined trends over time in the percent of STEMI patients admitted to hospitals categorized by PCI volume. Methods: Using comprehensive statewide hospital discharge data, we classified 191 acute care hospitals according to annual PCI volume: no PCI capability (n=90), low-volume (1-199 PCIs; n=33) medium volume (200-399 PCIs; n=4) and high-volume (400+ PCIs; n=64). Hospital classifications were specific for a 3-month time window; therefore a single hospital's category could vary over time. We determined the percent of STEMI patients treated at each type of hospital for the first and second half of each year from 2001-2007. Results: From early 2001 to late 2007, the percent of STEMI patients treated at non-PCI capable hospitals declined from 31.0 to 7.9%, while the proportion at high-volume PCI centers rose from 58.3 to 72.3%. Low- and medium-volume hospitals typically accounted for <15% of total patient volume but realized slight increases from 2001 to 2007. The percentage of STEMI patients seen at low-volume PCI hospitals rose from 6.6 to 8.7% from 2001-2007, and from 4.2% to 11.1% at medium-volume hospitals. No differences in the hospital admission trends were observed by race/ethnicity or gender. Conclusions: The pattern of STEMI care has changed substantially from 2001-2007 in Florida, with a greater proportion of patients seen at high-volume PCI hospitals and fewer than 10% admitted to non-PCI hospitals by 2007. These trends are likely due to implementation of STEMI protocols by many large emergency medical services (EMS) providers across the state and the positive impact of local STEMI care coalitions in some metropolitan areas. Further research is needed to determine if there has been increased STEMI patient awareness of the value of undergoing PCI at high-volume centers. A positive trend toward regionalized STEMI care appears to be in progress in Florida.

Abstract 10: Hospital-Quality Following Percutaneous Coronary Intervention In Massachusetts: Experience From 2003-2008

Background: Little information is available on hospital performance following percutaneous coronary intervention (PCI) using all-comer populations. Using a fully Bayesian approach, Massachusetts has publicly reported all-cause in-hospital mortality (IHM) following PCI procedures performed since 04/01/2003 in all non-federal hospitals. Methods: Trained data managers prospectively collected information using the ACC-NCDR instrument supplemented by Mass-DAC specific elements. Operators and data managers adjudicated selected elements via chart review. Bayesian hierarchical regression models of IHM were estimated annually for two cohorts: (1) cardiogenic shock or ST-elevation myocardial infarction (STEMI); and (2) no shock and no STEMI. Posterior risk-standardized IHM rates were estimated. The odds of death for a patient treated at a hospital 1 SD below average quality relative to treatment at a hospital 1 SD above average quality quantified variation. Results: Presence of shock; emergent or salvage status; and compassionate use were changed after adjudication for more than one-quarter of adjudicated cases. No Shock and No STEMI Cohort: Between 04/03-09/08, the number of annual PCI admissions ranged from 11121-14504; number of hospitals from 14-22; and median post-PCI length of stay (LOS) remained unchanged (2 days). The crude IHM declined from 0.76% (81 of 10689) in 2003 to 0.50% (56 in 11275)in 2007. Model discrimination using 9 risk factors was high (ROC = 0.86). The odds of death at lower versus higher quality hospital ranged between 1.38 and 2.14. Shock or STEMI Cohort: the number of PCI admissions ranged from 2606-2800; number of hospitals from 18-24; and median post-PCI LOS remained unchanged (4 days). IHM declined from 6.86% (135 in 1968) in 2003 to 4.78% (130 in 2721)in 2008. Model discrimination was excellent using 7 covariates (ROC = 0.89). The odds of death at lower versus higher quality hospital ranged from 1.49 to 6.35. Conclusions: Key clinical factors, including shock, status of PCI, and compassionate use require adjudication. A small number of risk factors have excellent discrimination of in-hospital survivors at the patient level. Estimates of between-hospital variation can be used to quantify performance at the hospital level.

Akuter Myokardinfarkt: Akut-PCI in jedem Krankenhaus versus Akut-PCI im spezialisierten Zentrum

The acute coronary syndromes (ACS) are currently divided into those with ST elevation (STE-ACS = ST elevation myocardial infarction [STEMI]) and those without ST elevation (NSTE-ACS). The latter are further divided into NSTE-ACS with risk factors and NSTE-ACS without risk factors. For NSTE-ACS patients with risk factors an invasive strategy within 72 h after presentation is recommended, whereas NSTE-ACS patients without risk factors can be treated conservatively, without a routine invasive diagnosis. In patients with STE-ACS, primary angioplasty is the reperfusion therapy of choice. These recommendations concerning the invasive strategies are valid only under three conditions: (1) primary angioplasty has to be performed within 2 h after diagnosis of an STE-ACS; (2) door-to-balloon times for STE-ACS have to be < 60 min; (3) the invasive procedures have to be performed by experienced investigators at hospitals with a sufficient annual PCI (percutaneous coronary intervention) volume. The last point is based on studies which showed a volume-outcome relationship for PCIs in ACS patients and hospital mortality. In Germany, a nationwide supply with such an invasive strategy for ACS patients is currently possible, even within the recommended time frames. Therefore, local networks have to be established to achieve this goal. However, at least in regions with a high density of invasive centers, such networks should take the investigators' experience and the annual interventional volumes of the participating hospitals into account.

Do operator volumes relate to clinical outcomes after percutaneous coronary intervention in the Canadian health care system?

Many US studies have documented an association between operator volume and outcomes after percutaneous coronary intervention (PCI). No study has assessed whether this relationship exists in Canada, where PCI is performed only at a limited number of regional centers and operator volumes are higher. All PCI procedures performed in the province of Ontario from 1995 to 2001 were analyzed using administrative databases. The outcomes of interest were coronary artery bypass graft during the same hospitalization, mortality at 30 days, or the combined end point. A total of 38,561 PCI procedures were performed by 65 physicians at 8 centers. Over the study period, risk-adjusted coronary artery bypass graft rates fell from 2.0% in 1995 to 0.7% in 2000 (P < .0001) with no change in mortality. The median annual PCI volume was 132 (25th, 75th percentile: 81, 182) cases. After stratifying operators by average annual PCI volume into low (< 155 cases), intermediate (155-195 cases), and high (> 195 cases) volume, there were no significant linear relationships between risk-adjusted outcomes and operator terciles. No significant correlations were seen between individual PCI volume and risk-adjusted rates of mortality, bypass surgery, or the combined end point (P = .2, P = .35, and P = .95, respectively). In contrast to US studies, there does not appear to be an association between PCI volume and outcomes in Ontario. These findings may be related to the high annual volumes of most operators and institutions within Ontario.

Impact of interventionalist volume, experience, and board certification on coronary angioplasty outcomes in the era of stenting

It has been suggested that percutaneous coronary intervention (PCI) by high-volume operators may be associated with better outcomes. However, the relation between operator and outcome is confounded by hospital caseloads of PCI, with busier hospitals generally having better outcomes. We assessed the effect of operator characteristics (volume of PCI, years in practice, and board certification status) on contemporary outcomes of PCI in a busy center with high-volume operators. Between 1999 and 2001, 12,293 PCIs were performed at our center by 28 interventionalists. Patients' clinical risk was assessed with the previously validated Beaumont PCI Risk Score. Operators were classified as producing low, medium, or high volume (tertiles of annual PCI volume ≤92, 93 to 140, or >140, respectively), as less, medium, or great experience (tertiles of years in practice ≤8, 9 to 14, or >14 years, respectively), and board certified (68%) or not. In-hospital death rate and a composite end point (death, coronary artery bypass graft surgery, myocardial infarction, or stroke) occurred in 0.99% and 2.59% of patients, respectively. Operator volume, experience, and board certification showed no univariate or multivariate relation with the study end points. The Beaumont PCI Risk Score showed a strong independent relation with in-hospital death rate (adjusted odds ratio 1.37, 95% confidence interval 1.31 to 1.43, p <0.0001) and composite end point (odds ratio 1.19, 95% confidence interval 1.16 to 1.22, p <0.0001). We conclude that, in contemporary PCI practice at a large center with high-volume operators, in-hospital outcomes are not affected by operator volume, experience, or board certification. Rather, patients' clinical risk score is the overriding determinant of clinical outcomes. Our findings emphasize the power of a well-organized high-volume system to minimize the impact of operator factors on outcomes of PCI.

Hospital percutaneous coronary intervention volume and patient mortality, 1998 to 2000: Does the evidence support current procedure volume minimums?

ObjectivesThe aim of this study was to evaluate current American College of Cardiology/American Heart Association (ACC/AHA) hospital percutaneous coronary intervention (PCI) volume minimum recommendations. BackgroundIn order to reduce procedure-associated mortality, ACC/AHA guidelines recommend that hospitals offering PCIs perform at least 400 PCIs annually. It is unclear whether this volume standard applies to current practice. MethodsWe conducted a retrospective analysis of the Agency for Healthcare Research and Quality's Nationwide In-patient Sample hospital discharge database to evaluate in-hospital mortality among patients (n = 362,748) who underwent PCI between 1998 and 2000 at low (5 to 199 cases/year), medium (200 to 399 cases/year), high (400 to 999 cases/year), and very high (1,000 cases or more/year) PCI volume hospitals. ResultsCrude in-hospital mortality rates were 2.56% in low-volume hospitals, 1.83% in medium-volume hospitals, 1.64% in high-volume hospitals, and 1.36% in very high-volume hospitals (p < 0.001 for trend). Compared with patients treated in high-volume hospitals (odds ratio [OR] 1.00, referent), patients treated in low-volume hospitals remained at increased risk for mortality after adjustment for patient characteristics (OR 1.21, 95% confidence interval [CI] 1.06 to 1.28). However, patients treated in medium-volume hospitals (OR 1.02, 95% CI 0.92 to 1.14) and patients treated in very high-volume hospitals (OR 0.94, 95% CI 0.85 to 1.03) had a comparable risk of mortality. Findings were similar when high- and very high-volume hospitals were pooled together. ConclusionsWe found no evidence of higher in-hospital mortality in patients undergoing PCI at medium-volume hospitals compared with patients treated at hospitals with annual PCI volumes of 400 cases of more, suggesting current ACC/AHA PCI hospital volume minimums may merit reevaluation.

Volume-outcome relation for hospitals performing angioplasty for acute myocardial infarction: results from the Nationwide Japanese Registry.

The purpose of this study was to use a contemporary database to examine the relationship between annual hospital volume and the outcomes of percutaneous coronary interventions (PCIs) for acute myocardial infarction (AMI), given the wide spread use of coronary stents. An inverse relation exists between the number of PCIs and short-term outcome, but PCI practice has been changing with the availability of new devices such as stents. Data from the 1997 Japanese nationwide registry were analyzed to determine the relation between the annual hospital volume of PCI procedures for patients with AMI and in-hospital mortality, as well as the need for coronary artery bypass graft (CABG) surgery. A total of 129 hospitals (2,491 patients) were divided into terciles according to the annual volume. Of the procedures, 39% involved coronary stents. Median annual PCI volumes varied across terciles from low =10, middle =33, and high =89. After adjusting for patient characteristics, there was no significant relationship between volume and in-hospital mortality (trend P=0.66) and CABG (trend P=0.35). Among patients who received stents (n=958), there was no significant association between volume and either mortality or CABG. Using the contemporary database, there was no significant relationship between hospital volume and in-hospital outcome among AMI patients undergoing PCIs.