CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY
Relationship Between Operator Volume and Adverse Outcome in Contemporary Percutaneous Coronary Intervention Practice
An Analysis of a Quality-Controlled Multicenter Percutaneous Coronary Intervention Clinical Database
Mauro Moscucci, MD*,*,
David Share, MD, MPH*,
Dean Smith, PhD ,
Michael J. O'Donnell, MD ,
Arthur Riba, MD ,
Richard McNamara, MD||,
Thomas Lalonde, MD¶,
Anthony C. Defranco, MD#,
Kirit Patel, MD**,
Eva Kline Rogers, RN, MS*,
Chris D'Haem, DO,
Milind Karve, MD and
Kim A. Eagle, MD*
* Division of Cardiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
St. Joseph Mercy Hospital, Ann Arbor, Michigan
Blue Cross Blue Shield of Michigan, Detroit, Michigan, USA
¶ St. John's Hospital and Medical Center, Detroit, Michigan
Oakwood Hospital, Dearborn, Michigan
|| Spectrum Health, Grand Rapids, Michigan
# McLaren Regional Medical Center, Flint, Michigan
** St. Joseph Hospital, Pontiac, Michigan
Ingham Regional Medical Center, Lansing, MichiganUSA
Sparrow Medical Center, Lansing, Michigan
Manuscript received September 24, 2004;
revised manuscript received May 10, 2005,
accepted May 22, 2005.
* Reprint requests and correspondence: Dr. Mauro Moscucci, University of Michigan Hospital, Division of Cardiology, Taubman Center B1-226, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109-0311
(Email: moscucci{at}med.umich.edu).
OBJECTIVES: The aim of our study was to evaluate the volume-outcome relationship in a large, quality-controlled, contemporary percutaneous coronary interventions (PCI) database.
BACKGROUND: Whether the relationship between physician volume of PCI and outcomes still exists in the era of coronary stents is unclear.
METHODS: Data on 18,504 consecutive PCIs performed by 165 operators in calendar year 2002 were prospectively collected in a regional consortium. Operators' volume was divided into quintiles (1 to 33, 34 to 89, 90 to 139, 140 to 206, and 207 to 582 procedures/year). The primary end point was a composite of major adverse cardiovascular events (MACE) including death, coronary artery bypass grafting, stroke or transient ischemic attack, myocardial infarction, and repeat PCI at the same site during the index hospital stay.
RESULTS: The unadjusted MACE rate was significantly higher in quintiles one and two of operator volume when compared with quintile five (7.38% and 6.13% vs. 4.15%, p = 0.002 and p = 0.0001, respectively). A similar trend was observed for in-hospital death. After adjustment for comorbidities, patients treated by low volume operators had a 63% increased odds of MACE (adjusted odds ratio [OR] 1.63, 95% confidence interval [CI] 1.29 to 2.06, p < 0.0001 for quintile [Q]1; adjusted OR 1.63, 95% CI 1.34 to 1.90, p < 0.0001 for Q2 vs. Q5), but not of in-hospital death. Overall, high volume operators had better outcomes than low volume operators in low-risk and high-risk patients.
CONCLUSIONS: Although the relationship between operator volume and in-hospital mortality is no longer significant, the relationship between volume and any adverse outcome is still present. Technological advancements have not yet completely offset the influence of procedural volume on proficiency of PCIs.
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Abbreviations and Acronyms
| | ACC = American College of Cardiology | | AHA = American Heart Association | | CABG = coronary artery bypass grafting | | CI = confidence interval | | MACE = major adverse cardiovascular events | | MI = myocardial infarction | | PCI = percutaneous coronary intervention | | Q = quintile |
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