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Exploring the Relationship Between Volume and Outcomes in Hospital Cardiovascular Care
James R Langabeer1, Junghyun Kim, Jeffrey Helton
1The University of Texas Health Science Center, Houston (Drs Langabeer and Kim); and Metropolitan State University, Denver, Colorado (Dr Helton).
Insights
Higher volume hospitals improve patient outcomes in interventional cardiovascular care. High-volume facilities demonstrated shorter door-to-balloon times and significantly lower mortality rates for ST-segment elevation myocardial infarction patients.
Area of Science:
- Cardiovascular Medicine
- Health Services Research
Background:
- Management theories suggest increased scale leads to improved performance.
- Guidelines recommend high-volume facilities for better cardiovascular care outcomes, but evidence is mixed.
- This study investigates the volume-outcome relationship in interventional cardiovascular care.
Purpose of the Study:
- To assess the relationship between hospital procedural volume and patient outcomes in interventional cardiovascular care.
- To evaluate if higher hospital volumes correlate with improved door-to-balloon times and reduced mortality for ST-segment elevation myocardial infarction (STEMI) patients.
Main Methods:
- Analysis of 9360 STEMI patients undergoing percutaneous intervention (PCI) from 2010-2015.
- Data sourced from 33 PCI-capable hospitals in the Dallas, Texas region via the National Cardiovascular Data Registry.
- Hospitals stratified into low, intermediate, and high procedural volume categories; multivariate analyses used to assess outcomes (door-to-balloon time, mortality).
Main Results:
- High-volume hospitals had significantly shorter door-to-balloon times (47 minutes) compared to intermediate (60 minutes) and low-volume (75 minutes) facilities (P < .001).
- Mortality rates were substantially lower in high-volume hospitals, with an unadjusted absolute reduction of 3.3%.
- Multivariate regression confirmed that hospital volume is a statistically significant predictor for both mortality and treatment times.
Conclusions:
- Higher-volume PCI hospitals achieve 37% shorter treatment times and 53% lower mortality rates than smaller facilities.
- This study provides robust evidence supporting a positive volume-outcome relationship in interventional cardiovascular care.
- Findings suggest that patient care for STEMI may benefit from centralization in high-volume centers.
Background:
Management theories of learning and experience curve effects state that greater levels of scale produce learnings and improved performance. In cardiovascular care, guidelines suggest that high-volume facilities produce better patient outcomes; yet, there are contradictory findings from the few studies conducted. Our goals were to assess the volume-outcome relationship for interventional cardiovascular care.
Methods:
We examined 9360 patients with ST-segment elevation myocardial infarction who underwent percutaneous intervention (PCI). We analyzed 6 years of data (2010-2015) using systematic extracts provided by 33 PCI-capable hospitals in the Dallas Texas region from the National Cardiovascular Data Registry. We stratified hospitals into 3 procedural volume categories (low, intermediate, and high) to identify changes in 2 key outcome metrics (ie, door-to-balloon times and mortality). Multivariate analyses and tests of differences were utilized.
Results:
Door-to-balloon performance outcome was significantly different between volume categories, with the highest-volume hospitals performing significantly better than intermediate- and low-volume hospitals (47, 60, and 75 minutes, respectively; P < .001). Mortality followed a similar pattern, with a 3.3% unadjusted absolute lower mortality rate for the high-volume hospitals. Multivariate regressions confirm that volume is statistically significant in both mortality and treatment times.
Conclusions:
Higher-volume PCI hospitals have 37% shorter treatment times and 53% lower mortality rates than smaller facilities. This study provides evidence of a positive volume-outcome relationship in interventional cardiovascular care.
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