Related Experiment Videos
Volume-based referral for cardiovascular procedures in the United States: a cross-sectional regression analysis
Andrew J Epstein1, Saif S Rathore, Harlan M Krumholz
1Division of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, USA. andrew.epstein@yale.edu
Insights
Implementing hospital volume minimums for coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) could save 728 lives annually in the US. However, moving many patients to high-volume centers to prevent fewer deaths raises questions of feasibility.
Area of Science:
- Cardiovascular Surgery
- Health Services Research
Background:
- The Leapfrog Group recommends minimum annual hospital procedure volumes for coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) to reduce mortality.
- These recommendations include 450 CABG and 400 PCI procedures annually per hospital.
Purpose of the Study:
- To estimate the number of patients affected and deaths avoided by adopting Leapfrog's recommended hospital procedure volume minimums for CABG and PCI.
- To evaluate the impact of centralizing care at high-volume hospitals on patient mortality.
Main Methods:
- Retrospective analysis of a national hospital discharge database (1998-2001) for CABG (n=1,496,937) and PCI (n=2,500,796) patients.
- Simulated the number of deaths averted by moving all patients from low-volume to high-volume hospitals under optimal conditions.
Main Results:
- Higher in-hospital mortality odds were observed for patients treated at low-volume hospitals for both CABG (OR 1.16) and PCI (OR 1.12).
- Adopting volume minimums would necessitate transferring 143,687 CABG and 87,661 PCI patients annually.
- An estimated 619 CABG deaths and 109 PCI deaths could be prevented annually.
Conclusions:
- Recommended hospital volume minimums for CABG and PCI could prevent 728 deaths annually in the US, a lower figure than previously estimated.
- The feasibility and effectiveness of policies requiring large-scale patient transfers to prevent a relatively small number of deaths remain uncertain.
Background:
We sought to estimate the numbers of patients affected and deaths avoided by adopting the Leapfrog Group's recommended hospital procedure volume minimums for coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI). In addition to hospital risk-adjusted mortality standards, the Leapfrog Group recommends annual hospital procedure minimums of 450 for CABG and 400 for PCI to reduce procedure-associated mortality.
Methods:
We conducted a retrospective analysis of a national hospital discharge database to evaluate in-hospital mortality among patients who underwent PCI (n = 2,500,796) or CABG (n = 1,496,937) between 1998 and 2001. We calculated the number of patients treated at low volume hospitals and simulated the number of deaths potentially averted by moving all patients to high volume hospitals under best-case conditions (i.e., assuming the full volume-associated reduction in mortality and the capacity to move all patients to high volume hospitals with no related harms).
Results:
Multivariate adjusted odds of in-hospital mortality were higher for patients treated in low volume hospitals compared with high volume hospitals for CABG (OR 1.16, 95% CI 1.10-1.24) and PCI (OR 1.12, 95% CI 1.05-1.20). A policy of hospital volume minimums would have required moving 143,687 patients for CABG and 87,661 patients for PCI from low volume to high volume hospitals annually and prevented an estimated 619 CABG deaths and 109 PCI deaths. Thus, preventing a single death would have required moving 232 CABG patients or 805 PCI patients from low volume to high volume hospitals.
Conclusion:
Recommended hospital CABG and PCI volume minimums would prevent 728 deaths annually in the United States, fewer than previously estimated. It is unclear whether a policy requiring the movement of large numbers of patients to avoid relatively few deaths is feasible or effective.
