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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Hospital percutaneous coronary intervention volume and patient mortality, 1998 to 2000

Does the evidence support current procedure volume minimums?

Andrew J. Epstein, MPP^*, Saif S. Rathore, MPH, Kevin G. M. Volpp, MD, PhD^* and Harlan M. Krumholz, MD, SM, FACC^||¶,*

^* Department of Health Care Systems, Wharton School of Business, University of Pennsylvania, Philadelphia, Pennsylvania, USA
Department of Medicine, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
VA Center for Health Equity Research and Promotion, University of Pennsylvania, Philadelphia, Pennsylvania, USA
Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
^|| Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, USA
^¶ Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA

Manuscript received May 20, 2003; revised manuscript received September 15, 2003, accepted September 23, 2003.

^* Reprint requests and correspondence: Dr. Harlan M. Krumholz, Department of Internal Medicine, Yale University School of Medicine, Room I-465 SHM, 333 Cedar Street, PO Box 208025, New Haven, Connecticut 06520-8025, USA.

Presented, in part, at the 2003 American College of Cardiology Scientific Sessions, Chicago, Illinois, April 2, 2003.

OBJECTIVES: The 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.

BACKGROUND: In 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.

METHODS: We 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.

RESULTS: Crude 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.

CONCLUSIONS: We 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.

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/ American Heart Association   AHRQ = Agency for Healthcare Research and Quality   CI = confidence interval   ICD-9-CM = International Classification of Diseases-9th Revision-Clinical Modification   MI = myocardial infarction   NIS = Nationwide In-patient Sample   OR = odds ratio   PCI = percutaneous coronary intervention   SMR = standard mortality ratio

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