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Published on: July 18, 2014
Complications after complex device implantation: how important is implanter seniority?
Paul A Scott1,2, Antonio Cannata3, Daniel I Bromage3
1King's British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK paul.scott@kcl.ac.uk.
Insights
Operator seniority, not volume or hospital size, impacts reintervention risk after complex device implantation. Mid-career consultants showed lower reintervention rates, suggesting a U-shaped relationship between experience and patient outcomes.
Area of Science:
- Cardiology
- Medical Device Technology
- Health Services Research
Background:
- Procedure complication risks can be linked to operator and institutional factors.
- Investigating the impact of consultant experience and volume on reintervention after complex device implantation is crucial.
Purpose of the Study:
- To assess if supervising consultant seniority, operative volume, and hospital volume influence reintervention risk following complex device implantation.
Main Methods:
- A nationwide population-based study analyzed data from England (April 2014-March 2019).
- Included first transvenous implantable cardioverter defibrillator or cardiac resynchronisation therapy (CRT) implants.
- Used multilevel logistic regression to evaluate associations between 1-year reintervention and operator/hospital volume and seniority.
Main Results:
- No association found between increasing supervising consultant volume and reintervention risk.
- A borderline significant association between operator volume and reintervention was observed for CRT-pacemakers/defibrillators in the highest volume quartile.
- A U-shaped relationship was identified between reintervention risk and supervising consultant seniority, with mid-seniority operators showing lower risk.
Conclusions:
- Operator seniority exhibits a U-shaped association with reintervention risk for complex devices.
- Newly qualified consultants may benefit from mentorship, and all operators should engage in continuous outcome evaluation and sharing.
Background:
The complication risk of procedures may be influenced by operator and institutional characteristics. Our aim was to assess whether supervising consultant seniority and operative volume, and hospital volume were associated with the risk of reintervention following complex device implantation.
Methods:
A nationwide population-based study was performed using the National Institute for Cardiovascular Outcomes Research registry including all patients receiving their first transvenous implantable cardioverter defibrillator or cardiac resynchronisation therapy (CRT) implant in England over 5 years (April 2014-March 2019). The primary endpoint was 1-year reintervention. We evaluated the association between reintervention and supervising consultant annualised complex device volume, supervising consultant seniority and hospital annualised complex device volume, using multilevel logistic regression.
Results:
47 630 implants were included. The 1-year reintervention rate was 6.1% (N=2916). There was no difference in reintervention risk with increasing supervising consultant volume (OR 0.89 Q4 vs Q1; 95% CI 0.76 to 1.05, p=0.17). When CRT-pacemakers/defibrillators implants were analysed separately (N=26 108), there was an association between operator volume and 1-year reintervention, but this was of borderline statistical significance and only evident in the highest compared with the lowest volume quartile of operators (adjusted OR 0.79 Q4 vs Q1; 95% CI 0.63 to 0.98, p=0.03). There was a non-linear relationship between reintervention risk and supervising consultant seniority, with the operators in the middle two quartiles of seniority having a lower risk (OR 0.87 Q2 vs Q1, p=0.02; OR 0.81 Q3 vs.Q1; p=0.003) while the most and least senior operators had a similar reintervention risk (OR 0.93 Q4 vs Q1, p=0.31). Hospital volume was not associated with 1-year reintervention.
Conclusions:
There is a U-shaped curve between operator seniority and reintervention risk for complex devices. Although there are several potential explanations, these data suggest that while newly qualified consultants may benefit from mentoring, all operators should continuously evaluate their outcomes and share them within their centre and more widely through the national audit.
