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Total Center Percutaneous Coronary Intervention Volume and 30-Day Mortality: A Contemporary National Cohort Study of
Darragh O'Neill1, Owen Nicholas2, Chris P Gale2
1From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.). d.oneill@ucl.ac.uk.
Insights
This study found no link between hospital procedural volume and patient outcomes after percutaneous coronary intervention (PCI). Lower-volume centers did not show worse mortality rates for PCI patients in the UK.
Area of Science:
- Cardiovascular Medicine
- Health Services Research
- Interventional Cardiology
Background:
- Uncertainty exists regarding the relationship between procedural volume and patient prognosis following percutaneous coronary intervention (PCI).
- Previous studies have yielded conflicting results on whether higher procedural volumes correlate with better outcomes.
- This study offers a contemporary evaluation using a comprehensive, nationally representative registry in the UK.
Purpose of the Study:
- To investigate the association between hospital procedural volume and patient outcomes after percutaneous coronary intervention (PCI).
- To provide a contemporary reassessment of the volume-outcome relationship in a national healthcare system.
- To determine if lower-volume centers have worse or better prognosis for PCI patients.
Main Methods:
- A nationwide cohort study utilizing the British Cardiovascular Intervention Society registry.
- Analysis of adult patients undergoing PCI in 93 English and Welsh hospitals between 2007 and 2013.
- Hierarchical modeling with risk adjustment for patient factors and case mix.
Main Results:
- A total of 427,467 PCI procedures were analyzed, with a 30-day mortality of 1.9% overall and 4.8% for primary PCI.
- Center case mix varied with volume; lower-volume centers performed a smaller proportion of primary PCI but a higher proportion of ST-segment-elevation myocardial infarction with cardiogenic shock.
- Risk-adjusted analysis revealed no significant evidence of worse or better outcomes in lower-volume centers for both overall PCI and primary PCI.
Conclusions:
- This study supports the conclusion that there is no trend for increased mortality in lower-volume centers for PCI within the UK healthcare system.
- After adjusting for case mix and clinical presentation, outcomes were not significantly different based on procedural volume.
- The findings contribute to the understanding of healthcare quality and resource allocation in interventional cardiology.
Background:
The relationship between procedural volume and prognosis after percutaneous coronary intervention (PCI) remains uncertain, with some studies finding in favor of an inverse association and some against. This UK study provides a contemporary reassessment in one of the few countries in the world with a nationally representative PCI registry.
Methods And Results:
A nationwide cohort study was performed using the national British Cardiovascular Intervention Society registry. All adult patients undergoing PCI in 93 English and Welsh NHS hospitals between 2007 and 2013 were analyzed using hierarchical modeling with adjustment for patient risk. Of 427 467 procedures (22.0% primary PCI) in 93 hospitals, 30-day mortality was 1.9% (4.8% primary PCI). 87.1% of centers undertook between 200 and 2000 procedures annually. Case mix varied with center volume. In centers with 200 to 399 PCI cases per year, a smaller proportion were PCI for ST-segment-elevation myocardial infarction (8.4%) than in centers with 1500 to 1999 PCI cases per year (24.2%), but proportionally more were for ST-segment-elevation myocardial infarction with cardiogenic shock (8.4% versus 4.3%). For the overall PCI cohort, after risk adjustment, there was no significant evidence of worse, or better, outcomes in lower volume centers from our own study, or in combination with results from other studies. For primary PCI, there was also no evidence for increased or decreased mortality in lower volume centers.
Conclusions:
After adjustment for differences in case mix and clinical presentation, this study supports the conclusion of no trend for increased mortality in lower volume centers for PCI in the UK healthcare system.
Clinical Trial Registration:
https://www.clinicaltrials.gov. Unique identifier: NCT02184949.
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