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The relationship between coronary angioplasty procedure volume and major complications
S E Kimmel1, J A Berlin, W K Laskey
1Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA.
Insights
Higher cardiac catheterization laboratory volume correlates with fewer major complications from percutaneous transluminal coronary angioplasty (PTCA). Current guidelines for minimum lab volume may be insufficient, suggesting higher volumes are needed for better patient outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Services Research
Background:
- The volume of procedures performed in a cardiac catheterization laboratory is a potential indicator of quality.
- Current guidelines recommend a minimum laboratory volume for percutaneous transluminal coronary angioplasty (PTCA).
Purpose of the Study:
- To examine the association between PTCA procedure volume and major complications.
- To assess if current minimum laboratory volume guidelines are adequate.
Main Methods:
- A cohort study utilizing data from the 1992-1993 Society for Cardiac Angiography and Interventions registries.
- Included 19,594 patients undergoing their first coronary balloon angioplasty, excluding those with acute myocardial infarction.
- Analyzed outcomes including emergency bypass surgery, myocardial infarction, and in-hospital death.
Main Results:
- Increasing PTCA volume was associated with decreased rates of in-hospital mortality, emergency bypass surgery, myocardial infarction, and major complications.
- These associations remained significant after adjusting for patient case mix.
- Laboratories performing over 400 procedures annually showed significantly fewer major complications compared to those performing under 200.
Conclusions:
- A clear inverse relationship exists between cardiac catheterization laboratory volume and major PTCA complications, independent of patient risk.
- The current recommended minimum laboratory volume may not be sufficient to differentiate between high- and low-risk laboratories.
Objective:
To assess the relationship between the volume of percutaneous transluminal coronary angioplasty (PTCA) procedures performed in a cardiac catheterization laboratory and major complications after adjusting for case mix and to evaluate the applicability of current guidelines for minimum laboratory volume.
Design:
Cohort study using the 1992 and 1993 registries of the Society for Cardiac Angiography and Interventions.
Setting:
Forty-eight cardiac catheterization laboratories from throughout the United States and Canada.
Patients:
All 19 594 consecutive patients without an acute myocardial infarction (MI) undergoing a first coronary balloon angioplasty.
Main Outcome Measures:
Emergency bypass surgery, MI, or in-hospital death.
Results:
There was a significant decrease in the rates of in-hospital mortality (P = .04), emergency bypass surgery (P < .001), MI (P - .001), and major complications (defined as one or more of these outcomes; P < .001) with increasing cardiac catheterization laboratory volume. After adjustment for case mix using multivariable analysis, these associations persisted, although the association with mortality was no longer statistically significant. There was no significant difference in outcomes in laboratories performing at least 200 vs fewer than 200 procedures per year, the currently recommended minimum laboratory volume (odds ratio [OR] for major complications, 0.81; 95% confidence interval [CI], 0.53 to 1.25). However, a statistically significant decrease in major complications was observed in laboratories performing more than 400 procedures per year (adjusted OR, 0.66; 95% CI, 0.46 to 0.96; P = .03; and OR, 0.54; 95% CI, 0.38 to 0.78; P = .001) when laboratories performing 400 through 599 procedures and at least 600 procedures per year, respectively, are compared with those performing fewer than 200 per year.
Conclusions:
An inverse association between cardiac catheterization laboratory procedure volume and major complications during PTCA exists independent of differences in patients' risk profiles. Our data suggest that the currently recommended minimum laboratory volume may be too low to distinguish higher-risk from lower-risk laboratories.
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