Number Of High-volume Centers Research Articles

Regional variability of cardiovascular magnetic resonance access and utilization in the United States

Clinical guidelines and scientific data increasingly support the appropriate use of cardiovascular magnetic resonance (CMR) . The extent of CMR adoption across the United States (US) remains unclear. This observational analysis aims to capture CMR practice patterns in the US. Commissioned reports from the Society for Cardiovascular Magnetic Resonance (SCMR), pre-existing survey data from CMR centers, and socioeconomic and coronary heart disease data from the Centers for Disease Control and Prevention were used. The location of imaging centers performing CMR was based on 2018 Medicare claims. Secondary analysis was performed on center-specific survey data from 2017-2019, which were collected by members of the SCMR US Advocacy Subcommittee for quality improvement purposes. The correlation between the number of imaging centers billing for CMR services per million persons, socioeconomic determinants, and coronary heart disease epidemiology was determined. A total of 591 imaging centers billed the Center for Medicare & Medicaid Services for CMR services in 2018 and 112 (of 155) unique CMR centers responded to the survey. In 2018, CMR services were available in almost all 50 states. Minnesota was the state with the highest number of CMR centers per million Medicare beneficiaries (52.6 centers per million), and Maine had the lowest (4.4 per million). The total density of CMR centers was 16 per million for US Medicare beneficiaries. Sixty-eight percent (83 of 112) of survey responders were cardiologists, and 28% (31/112) were radiologists. In 72% (71/112) of centers, academic health care systems performed 81%-100% of CMR exams. The number of high-volume centers (>500 scans per year) increased by seven between 2017 and 2019. In 2019, 53% (59/112) of centers were considered high-volume centers and had an average of 19years of experience. Centers performing <50 scans had on average 3.5years of experience. Approximate patient wait time for a CMR exam was 2weeks to 1month. Despite increasing volume and availability in almost all 50 states, CMR access remains geographically variable. Advocacy efforts to improve access and innovations that reduce imaging time and exam complexity have the potential to increase the adoption of CMR technology.

295 High Volume Centers Provide Superior Value of Care in the Surgical Treatment of Malignant Brain Tumor

INTRODUCTION: Improved outcomes in surgical patients have been associated with increasing volume of cases. This has led to the development of centers that facilitate care for a specific patient population. METHODS: The 2016-2020 National Inpatient Sample (NIS) was queried for patients undergoing resection of malignant brain tumors. Teaching hospitals with high case load (greater than two standrad deviations above the mean, or &gt;140 cases) were categorized as high-volume centers (HVC). Value of care was computed by adding one point for each of the following variables: lower length of stay, lower total charges, discharge to home, and lack of major comorbidity or complication, as defined per DRG codes. RESULTS: A total of 118,390 patients underwent resection of malignant brain tumors in 3,009 hospitals. HVC criteria was met by 91 (3%) hospitals, which represented 20,230 (17.1%) of total cases. The Mid-Atlantic and South Atlantic regions had the highest percentage of cases (22.7% and 20.2%, respectively) and number of HVC (21 and 17, respectively). Value of care was higher at HVC (OR = 1.35 95%CI 1.31-1.39 p &lt; 0.01). After controlling for baseline risk factors and high risk admissions, HVC was associated with decreased complications of intracranial hemorrhage, deep venous thrombosis, aspiration pneumonitis, acute kidney injury, and external ventricular drain requirement (p &lt; 0.01 for all). HVC was also associated with decreased length of stay and increased rate of discharge to home (p &lt; 0.01 for both). CONCLUSIONS: Patients undergoing craniotomy for malignant brain neoplasms have superior outcomes in HVC. Trends of centralization are likely a reflection of the benefits of multidisciplinary treatment for these patients. Improvement of access to care at these institutions may improve the efficiency of the delivery of care for these patients.

High-Volume Centers Provide Superior Value of Care in the Surgical Treatment of Malignant Brain Tumor

Improved outcomes in surgical patients have been associated with increasing volume of cases. This has led to the development of centers that facilitate care for a specific patient population. To evaluate associations of outcomes with hospital characteristics in patients undergoing resection of malignant brain tumors. The 2016-2020 National Inpatient Sample (NIS) was queried for patients undergoing resection of malignant brain tumors. Teaching hospitals with case loads greater than two standard deviations above the mean (140 cases) were categorized as high-volume centers (HVC). Value of care (VoC) was evaluated by adding one point for each of the following: short length of stay, low total charges, favorable discharge disposition, and lack of major comorbidity or complication. A total of 118,390 patients underwent resection of malignant brain tumors in 3009 hospitals. HVC criteria was met by 91 (3%) hospitals. HVC were more likely to treat patients of younger age or higher socioeconomic status (p < 0.01 for all). The Mid-Atlantic and South Atlantic regions had the highest percentage of cases and number of HVC. VoC was higher at HVC (p < 0.01). HVC was associated with decreased complications (p < 0.01 for all) and improved patient outcomes (p < 0.01 for all). Patients undergoing craniotomy for malignant brain neoplasms have superior outcomes in HVC. Trends of centralization may be a reflection of the benefits of multidisciplinary treatment, geographic preferences, publicity, and cultural impact. Improvement of access to care is an important consideration as this trend continues.

High and Low Frequency Domino Liver Transplantation Centers Demonstrate Similar Performance Outcomes

A Domino Liver Transplant (DLT) is a successfully validated surgical option for a subset of patients awaiting liver transplant. Increased utilization of DLTs could increase the donor organ pool. However, DLTs occur primarily at a small number of high volume centers, and are rarely performed at lower volume transplant centers. This study compares DLT recipient performance outcomes between high frequency DLT centers and low frequency DLT centers. The UNOS/OPTN STAR database was queried for DLTs performed at transplant centers between 1996-2018. 193 patients were identified and categorized into high (>5 DLTs) or low (≤5 DLTs) frequency centers. Our primary endpoint was allograft survival. Our secondary endpoints were graft status at last follow up and mortality secondary to cardiac, renal, or respiratory failure. Overall median allograft survival between high and low volume DLT centers was similar (48.2 months versus 42.7 months, P >0.314). The one-year (82% versus 76%), three-year (57% versus 56%), and five-year (45% versus 43%) survival percentages were also similar between the high and low volume DLT centers respectively. Overall mortality from cardiac (high 4% versus low 1.7%), renal (high 0.8% versus low 1.7%), or respiratory failure (high 0.8% versus low 1.7%) was similarly low in both groups. Low volume and high volume DLT centers are associated with similar outcomes of allograft survival and mortality. DLTs should be utilized more frequently, when the criteria are met, including in centers with limited experience, to expand the donor pool, decrease time on the waitlist, and improve overall survival.

Position paper of French Interventional Group (GACI) for TAVI in France in 2018

Aortic stenosis is a frequent disease in the elderly. Its prevalence is 0.4% with a sharp increase after the age of 65, and its outcome is very poor when the patient becomes symptomatic. The interventional procedure known as TAVI (trans-catheter aortic valve implantation), which was developed in France and carried out for the first time in Rouen by Prof. Alain Cribier and his team in 2002, has proven to be a valid alternative to surgical aortic valve replacement. At first, this technique was shown to be efficient in patients with contra-indications to surgical treatment or deemed to be at high surgical risk. Given the very promising outcomes achieved as a result of close heart team collaboration, appropriate patient selection, simplified procedures and reduced complication rates, transfemoral (TF) TAVI is now preferred in symptomatic intermediate risk patients>75 years old according to the latest ESC guidelines. In 2017, in France, TAVI is currently performed in 50 centers with on-site cardiac surgery. The 2016 TAVI outcomes recorded in the French national TAVI registry (France TAVI) are very encouraging and show that for 7133 patients treated (age 83.4±7 years, logistic Euroscore 14%), 87% of whom via the TF approach, cross-over to surgery was very low (0.5%) with a 3.0% in-hospital mortality rate. The substantial increase in TAVI indications and the improvement of its outcomes may in the near future call for a reconsideration of the number of high volume centers authorized to carry out this technique.

Robot-Assisted Laparoscopic Radical Cystectomy with Stentless Intracorporeal Modified Ves.Pa Neobladder: Early Experience

Abstract Introduction: Bladder cancer represents 3% of all cancers and 7% of cancer deaths in the United States.1 A majority of bladder cancer is treatable at an early stage.1 However, radical cystectomy with urinary diversion is required for muscle invasive disease.1 Traditionally, an ileal conduit is used; however, this has significant quality-of-life (QOL) changes. A neobladder can spare some of the QOL changes. All neobladders must use detubularization, double folding, creation of a spheroid shape, and efficient evacuation.2 Pure intracorporeal robot-assisted laparoscopic technique has been recently developed with a select number of high-volume centers utilizing various operative and neobladder techniques.3–5 Recently, the robotic Ves.Pa neobladder was described in a human pelvic model.6 We present our step-by-step process of the robot-modified Ves.Pa neobladder. Materials and Methods: The modified robotic Ves.Pa neobladder was completed using the da Vinci SI surgical system. Cystoprostatectomy was co...

The Relationship between Centralization of Care and Geographic Barriers to Cystectomy for Bladder Cancer.

Background: Centralization of cystectomy treatment for bladder cancer, while associated with improved outcomes, may impose geographic barriers to care. However, whether this effect may be counterbalanced by an increased number of high volume centers has not previously been explored.Objective: To characterize changes in geographic disparities to high volume cystectomy centers over time.Methods: Data on all inpatient admissions for cystectomy in New York State (NYS) from 1997–2011 was obtained from the Department of Health. Using these data, we classified hospitals according to cystectomy volume and measured patient distance traveled to a cystectomy center. Population weights, from the US Census, were used to describe changes in minimum travel distance to high- or very high-volume (HV/VHV) facilities across the NYS population.Results: Bladder cancer patients underwent cystectomies at 195 hospitals during the study period. In 1997–2001, eleven HV/VHV facilities accounted for 37.5% of all cystectomies, while sixteen HV/VHV hospitals accounted for 71.5% of all procedures during 2007–2011. Median distance traveled by cystectomy patients to all hospitals increased from 9.6 to 14.4 miles in 1997–2001 to 2007–2011, respectively. In the same time span, the median travel distance for the NYS population to a HV/VHV center decreased by 1.9 and 9.4 miles at the median and 75th percentile, respectively.Conclusions: Our findings demonstrate a complicated relationship between centralization and geographic access. While centralization has led to a decrease in overall access to cystectomy facilities, the process simultaneously improved access to high volume centers.

Abstract 22: STEMI Trends in the United States 2002-2010: Increasing Use of PCI and Declining Mortality

Objective: We sought to quantify changes in STEMI mortality and percutaneous coronary intervention (PCI) use in the United States (US) from 2002 to 2010. Methods: We used the Nationwide Inpatient Sample (NIS), an all-payer discharge database, to create estimates of STEMI, STEMI in-hospital mortality, and PCI use. The NIS includes hospitals selected to approximate 20% of all non-federal US hospitals and includes weights to create national estimates. STEMI cases were identified based on primary diagnostic code. High volume STEMI-PCI centers were defined as &gt;36 cases/year, according to PCI guidelines. Temporal trends were evaluated with logistic regression, adjusted for patient and hospital characteristics. Discharges to other acute care facilities were excluded for outcomes analyses. Results: We identified 1,944,112 STEMI discharges in the US; mean age was 64 years, 34% were women, and 46% were Medicare insured. The absolute number of STEMI discharges declined from 299,441 in 2002 to 167,929 in 2010 (Figure). The number of hospitals performing zero STEMI-related PCIs decreased from 75% (3633/4840) to 68% (3514/5134) between 2002 and 2010. The number of high volume centers increased from 20% (949/4840) to 24% (1235/4840) over the same period. Overall, 64% (1,145,196/1,783,825) of discharges received PCI and 8.5% (151,528/1,783,825) died during hospitalization. PCI use increased and mortality decreased over time (Figure). The adjusted odds of PCI use for STEMI discharges increased over three fold during the study period (OR 3.51 in 2010 versus 2002, 95% CI 3.21 to 3.83). The adjusted odds of death decreased by one fifth (OR 0.81 in 2010 versus 2002, 95% CI 0.75 to 0.87). Inclusion of PCI in the model attenuated the effect of year on death (OR 1.06 in 2010 versus 2002, 95% CI 0.98 to 1.14). Conclusions: In this study we demonstrate favorable trends in STEMI outcomes. Between 2002 and 2010, the absolute number of STEMIs in the US decreased, while more hospitals provided PCI for STEMI. Over time, more discharges were treated with PCI and fewer died during hospitalization.

E-009 Treatment of ruptured cerebral aneurysms is increasingly occurring in high volume centers in the USA

PurposeAlthough there is no formal system for regionalization of care for subarachnoid hemorrhage, evidence of better outcomes at higher volume centers might be expected to result in more of these...

A farewell to arms: Are complex fractionated atrial electrograms doomed as a target for AF ablation?

Ablative procedures to cure atrial fibrillation (AF) have gained popularity worldwide and prompted the development of new, complex, and expensive tools to achieve a high level of success (new energy sources, ablation tools, sophisticated mapping systems, etc). Despite the initial reports of very high procedural success, later revelations from a number of high-volume centers have postulated a more modest efficacy that decreases further with higher complexity and chronicity of AF substrate. Long-term maintenance of sinus rhythm has also been called into question recently.

Has Recognition of the Relationship Between Mortality Rates and Hospital Volume for Major Cancer Surgery in California Made a Difference?

Previous reports showed that in California during the early 1990s, operative mortality rates for esophageal, pancreatic, and hepatic cancers were inversely related to hospital volume. It is unknown whether this information has affected referral patterns or operative mortality rates. Data were analyzed for the 10 years that followed the period covered in the initial studies to determine if: (a) the operative mortality rates had decreased; and (b) a greater proportion of patients with esophageal, pancreatic, and hepatic cancers were treated at high-volume centers. Hospital discharge data were obtained for 8901 patients who had resections for cancer of the esophagus, 2404 patients; pancreas, 5294 patients; and liver, 1203 patients in California between 1995 and 2004. Logistic regression models were used to calculate adjusted mortality rates at high- and low-volume centers by year. The data were compared with the published results for California during the years 1990-1994. Operative mortality rates decreased for esophageal, pancreatic, and hepatic resections during the more recent 10 years. Concomitantly, the proportion of patients treated at high-volume centers increased, as did the number of high-volume centers. There was a substantial increase in the proportion of esophagectomies performed in high-volume hospitals, while the overall number of esophagectomies dropped by 22%. For the other 2 operations, total volume and the volume in high-volume hospitals increased greatly, and the volume in low-volume hospitals was about the same during the 3 periods. The mortality rates decreased at all levels of the volume range. Finally, the performance from one period to the next in individual hospitals was mostly similar, but an occasional outlier was also noted. More resections for esophageal, pancreatic, and hepatic cancer were performed at high volume centers, but mortality rates decreased for all hospital categories. The data suggest that modern hospitals act as complex adaptive systems, whose outputs are determined from the interactions between internal agents and are resistant to analysis by isolating and studying the individual contributions. It is tempting to attribute the desirable changes in these data (eg, more operations being done in high volume centers and better mortality rates at all levels) as consequences of pressures over the past few decades on hospitals to assume greater responsibility for their quality of care and to become more integrated internally.Thus, many factors appear to influence the volume-outcome relationships, and the identity and individual contributions of these influences may be immune to reductionist analysis. There is substantial evidence that high volume should be part of high quality for these complex operations. Nevertheless, measuring outcomes directly, rather than concentrating on their correlates, may be a more reliable index of hospital performance.