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Effect of physician volume on the relationship between hospital volume and mortality during primary angioplasty
V S Srinivas1, Susan M Hailpern2, Elana Koss1
1Department of Medicine, Division of Cardiology, Montefiore Medical Center, Bronx, New York.
Insights
High-volume hospitals and physicians performing primary percutaneous coronary intervention (PCI) reduce in-hospital mortality. Physician experience is a key factor in the hospital volume-outcome relationship for PCI, influencing patient survival rates.
Area of Science:
- Cardiology
- Health Services Research
- Outcomes Research
Background:
- A well-established inverse relationship exists between procedural volume and patient outcomes for primary percutaneous coronary intervention (PCI) in acute myocardial infarction.
- Both hospital and individual physician experience are independently associated with patient outcomes after PCI.
Purpose of the Study:
- To investigate the combined impact of hospital and physician volume on in-hospital mortality following primary PCI.
- To determine if physician experience modifies the relationship between hospital volume and patient outcomes.
Main Methods:
- Analysis of 7,321 patients undergoing primary PCI for acute myocardial infarction using the New York State PCI registry.
- Comparison of risk-adjusted mortality rates between high-volume (>50 cases/year) and low-volume hospitals, and high-volume (>10 cases/year) and low-volume physicians.
Main Results:
- Primary PCI performed in high-volume hospitals (OR: 0.58) and by high-volume physicians (OR: 0.66) was associated with significantly lower odds of in-hospital mortality.
- A significant interaction was observed between hospital and physician volume (p = 0.02), indicating their combined effect on mortality.
- In high-volume hospitals, high-volume physicians had lower risk-adjusted mortality (3.8%) compared to low-volume physicians (6.5%).
Conclusions:
- Physician experience plays a critical role in modifying the hospital volume-outcome relationship for primary PCI.
- Policymakers should consider individual physician expertise when developing strategies to enhance patient access to and outcomes from primary PCI.
Objectives:
We sought to examine the combined effect of hospital and physician volume of primary percutaneous coronary intervention (PCI) on in-hospital mortality.
Background:
An inverse relationship between volume and outcome has been observed for both hospitals and physicians after primary PCI for acute myocardial infarction.
Methods:
Using the New York State PCI registry, we examined yearly hospital volume, physician volume, and risk-adjusted mortality in 7,321 patients undergoing primary PCI for acute myocardial infarction. Risk-adjusted mortality rates for high-volume hospitals (>50 cases/year) and high-volume physicians (>10 cases/year) were compared with their respective low-volume counterparts.
Results:
Primary PCI by high-volume hospitals (odds ratio [OR]: 0.58; 95% confidence interval [CI]: 0.38 to 0.88) and high-volume physicians (OR: 0.66; 95% CI: 0.48 to 0.92) was associated with lower odds of mortality. Furthermore, there was a significant interaction between hospital and physician volume on adjusted mortality (p = 0.02). Although unadjusted mortality was lower when primary PCI was performed by high-volume physicians in high-volume hospitals compared with low-volume physicians in low-volume hospitals (3.2% vs. 6.7%, p = 0.03), the risk-adjusted mortality rate was not statistically significant (3.8% vs. 8.4%, p = 0.09). In low-volume hospitals, the average risk-adjusted mortality rate for low-volume physicians was 8.4% versus 4.8% for high-volume physicians (OR: 1.44; 95% CI: 0.68 to 3.03). However, in high-volume hospitals, the risk-adjusted mortality rate for high-volume physicians was 3.8% versus 6.5% for low-volume physicians (OR: 0.58; 95% CI: 0.39 to 0.86).
Conclusions:
During primary PCI, physician experience significantly modifies the hospital volume-outcome relationship. Therefore, policymakers need to consider physician experience when developing strategies to improve access to primary PCI.
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