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Hospital percutaneous coronary intervention volume and patient mortality, 1998 to 2000: does the evidence support
Andrew J Epstein1, Saif S Rathore, Kevin G M Volpp
1Department of Health Care Systems, Wharton School of Business, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Insights
Current guidelines recommend 400 percutaneous coronary interventions (PCI) annually per hospital. This study found no increased mortality risk for PCI patients in medium-volume hospitals (200-399 cases/year), suggesting guideline reevaluation.
Area of Science:
- Cardiovascular Medicine
- Health Services Research
- Interventional Cardiology
Background:
- The American College of Cardiology/American Heart Association (ACC/AHA) recommends a minimum annual volume of 400 percutaneous coronary interventions (PCI) per hospital to reduce mortality.
- The applicability of this volume standard to current clinical practice remains uncertain.
Purpose of the Study:
- To evaluate the current American College of Cardiology/American Heart Association (ACC/AHA) hospital percutaneous coronary intervention (PCI) volume minimum recommendations.
- To assess the relationship between hospital PCI volume and in-hospital mortality.
Main Methods:
- Retrospective analysis of the Nationwide Inpatient Sample database (1998-2000).
- In-hospital mortality was evaluated for 362,748 patients undergoing PCI.
- Hospitals were categorized into low (5-199), medium (200-399), high (400-999), and very high (≥1000) PCI volume groups.
Main Results:
- Crude in-hospital mortality rates decreased with increasing PCI volume: 2.56% (low), 1.83% (medium), 1.64% (high), and 1.36% (very high) (p < 0.001).
- After adjustment, patients in low-volume hospitals had increased mortality risk (OR 1.21) compared to high-volume hospitals.
- Patients in medium-volume (OR 1.02) and very high-volume (OR 0.94) hospitals had comparable mortality risk to high-volume hospitals.
Conclusions:
- No evidence suggests higher in-hospital mortality for PCI patients treated at medium-volume hospitals compared to those at hospitals performing ≥400 PCIs annually.
- Current ACC/AHA PCI hospital volume minimums may require reevaluation based on these findings.
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 = 362748) 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 (1000 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.
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