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Relationship between operator volume and adverse outcome in contemporary percutaneous coronary intervention practice:
Mauro Moscucci1, David Share, Dean Smith
1Division of Cardiology, University of Michigan Medical Center, Ann Arbor, Michigan 48109-0311, USA. moscucci@med.umich.edu
Insights
Physician experience in percutaneous coronary interventions (PCI) still impacts patient outcomes, even with modern stents. Higher operator volume is linked to fewer major adverse cardiovascular events, highlighting the importance of procedural experience.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Health Services Research
Background:
- The impact of physician procedural volume on outcomes after percutaneous coronary interventions (PCI) in the era of coronary stents remains incompletely understood.
- Assessing the volume-outcome relationship is crucial for quality control in interventional cardiology.
Purpose of the Study:
- To evaluate the contemporary volume-outcome relationship in a large, quality-controlled percutaneous coronary interventions (PCI) database.
- To determine if physician experience influences patient outcomes in modern PCI procedures.
Main Methods:
- Analysis of 18,504 consecutive PCIs performed by 165 operators in 2002, prospectively collected in a regional consortium.
- Operators were categorized into quintiles based on annual procedure volume (1-582 procedures/year).
- Primary endpoint was a composite of major adverse cardiovascular events (MACE), including death, need for coronary artery bypass grafting, stroke, myocardial infarction, and repeat PCI during hospitalization.
Main Results:
- Unadjusted MACE rates were significantly higher for operators in the lowest volume quintiles (Q1 and Q2) compared to the highest (Q5).
- After adjusting for comorbidities, patients treated by low-volume operators (Q1 and Q2) had a 63% increased odds of MACE compared to high-volume operators (Q5).
- A trend for higher in-hospital death was observed in lower volume quintiles, though not statistically significant after adjustment. High-volume operators demonstrated better outcomes across risk strata.
Conclusions:
- The relationship between operator volume and in-hospital mortality is no longer statistically significant.
- A significant association persists between lower procedural volume and increased risk of any major adverse cardiovascular event (MACE).
- Technological advancements in PCI have not fully mitigated the impact of operator experience on procedural proficiency and patient outcomes.
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.
