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CLINICAL STUDIES

The relationship between operator volume and outcomes after percutaneous coronary interventions in high volume hospitals in 1994–1996¹

The northern New England experience

David J. Malenka, MD, FACC^* , Paul D. McGrath, MD, MSc, FACC , David E. Wennberg, MD, MPH , Thomas J. Ryan, Jr., MD, FACC, Mirle A. Kellett, Jr, MD, FACC, Samuel J. Shubrooks, Jr., MD, FACC^||, William A. Bradley, MD, FACC, Bruce D. Hettlemen, MD, FACC^*, John F. Robb, MD, FACC^*, Michael J. Hearne, MD, FACC, Theodore M. Silver, MD, FACC^¶, Matthew W. Watkins, MD, FACC^#, John R. O’Meara, MD, FACC, Peter N. VerLee, MD, FACC^¶, Daniel J. O’Rourke, MD, MSc, FACC^* for the Northern New England Cardiovascular Disease Study Group

^* Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
Center for Evaluative and Clinical Sciences, Dartmouth Medical School, Hanover, New Hampshire, USA
Division of Health Services Research and the Division of Cardiology, Department of Medicine, Maine Medical Center, Portland, Maine, USA
Catholic Medical Center, Manchester, New Hampshire, USA
^|| Division of Cardiology, Beth Israel Deaconess Medical Center—West Campus, Boston, Massachusetts, USA
^¶ Division of Cardiology, Eastern Maine Medical Center, Bangor, Maine, USA
^# Division of Cardiology, Fletcher Allen Health Care, Burlington, Vermont, USA

Manuscript received December 17, 1998; revised manuscript received May 4, 1999, accepted July 19, 1999.

Reprint requests and correspondence: David J. Malenka, Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756
david.malenka{at}hitchcock.org

OBJECTIVES

The purpose of this study was to examine the relationship between annual operator volume and outcomes of percutaneous coronary interventions (PCIs) using contemporaneous data.

BACKGROUND

The 1997 American College of Cardiology (ACC)/American Heart Association task force based their recommendation that interventionists perform 75 procedures per year to maintain competency in PCI on data collected largely in the early 1990s. The practice of interventional cardiology has since changed with the availability of new devices and drugs.

METHODS

Data were collected from 1994 through 1996 on 15,080 PCIs performed during 14,498 hospitalizations by 47 interventional cardiologists practicing at the five high volume (>600 procedures per hospital per year) hospitals in northern New England and one Massachusetts- based institution that support these procedures. Operators were categorized into terciles based on their annualized volume of procedures. Multivariate regression analysis was used to control for case-mix. In-hospital outcomes included death, emergency coronary artery bypass graft surgery (eCABG), non-emergency CABG (non-eCABG), myocardial infarction (MI), death and clinical success (1 attempted lesion dilated to <50% residual stenosis and no death, CABG or MI).

RESULTS

Average annual procedure rates varied across terciles from low = 68, middle = 115 and high = 209. After adjusting for case-mix, clinical success rates were comparable across terciles (low, middle and high terciles: 90.9%, 88.8% and 90.7%, p_trend = 0.237), as were all the adverse outcomes including death (low-risk patients = 0.45%, 0.41%, 0.71%, p_trend = 0.086; high-risk patients = 5.68%, 5.99%, 7.23%, p_trend = 0.324), eCABG (1.74%, 2.05%, 1.75%, p_trend = 0.733) and MI (2.57%, 1.90%, 1.86%, p_trend = 0.065).

CONCLUSIONS

Using current data, there is no significant relationship between operator volumes averaging 68 per year and outcomes at high volume hospitals. Future efforts should be directed at determining the generalizability of these results.

Abbreviations and Acronyms   ACC = American College of Cardiology   CABG = coronary artery bypass graft   CI = confidence interval   CPK = creatine phosphokinase   eCABG = emergency coronary artery bypass graft   MI = myocardial infarction   OR = odds ratio   PCI = percutaneous coronary intervention

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