Relationship Between Operator Volume and Long-Term Outcomes After Percutaneous Coronary Intervention

Alexander C. Fanaroff, Pearl Zakroysky, Daniel Wojdyla, Lisa A. Kaltenbach, Matthew W. Sherwood, Matthew T. Roe, Tracy Y. Wang, Eric D. Peterson, Hitinder S. Gurm, Mauricio G Cohen, John C. Messenger, Sunil V. Rao

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

BACKGROUND: Although many studies show an inverse association between operator procedural volume and short-term adverse outcomes after percutaneous coronary intervention (PCI), the association between procedural volume and longer-term outcomes is unknown. METHODS: Using the National Cardiovascular Data Registry CathPCI registry data linked with Medicare claims data, we examined the association between operator PCI volume and long-term outcomes among patients ≥65 years of age. Operators were stratified by average annual PCI volume (counting PCIs performed in patients of all ages): low- (<50 PCIs), intermediate- (50-100), and high- (>100) volume operators. One-year unadjusted rates of death and major adverse coronary events (MACEs; defined as death, readmission for myocardial infarction, or unplanned coronary revascularization) were calculated with Kaplan-Meier methods. The proportional hazards assumption was not met, and risk-adjusted associations between operator volume and outcomes were calculated separately from the time of PCI to hospital discharge and from hospital discharge to 1-year follow-up. RESULTS: Between July 1, 2009, and December 31, 2014, 723 644 PCI procedures were performed by 8936 operators: 2553 high-, 2878 intermediate-, and 3505 low-volume operators. Compared with high- and intermediate-volume operators, low-volume operators more often performed emergency PCI, and their patients had fewer cardiovascular comorbidities. Over 1-year follow-up, 15.9% of patients treated by low-volume operators had a MACE compared with 16.9% of patients treated by high-volume operators ( P=0.004). After multivariable adjustment, intermediate- and high-volume operators had a significantly lower rate of in-hospital death than low-volume operators (odds ratio, 0.91; 95% CI, 0.86-0.96 for intermediate versus low; odds ratio, 0.79; 95% CI, 0.75-0.83 for high versus low). There were no significant differences in rates of MACEs, death, myocardial infarction, or unplanned revascularization between operator cohorts from hospital discharge to 1-year follow-up (adjusted hazard ratio for MACEs, 0.99; 95% CI, 0.96-1.01 for intermediate versus low; hazard ratio, 1.01; 95% CI, 0.99-1.04 for high versus low). CONCLUSIONS: Unadjusted 1-year outcomes after PCI were worse for older adults treated by operators with higher annual volume; however, patients treated by these operators had more cardiovascular comorbidities. After risk adjustment, higher operator volume was associated with lower in-hospital mortality and no difference in postdischarge MACEs.

Original languageEnglish (US)
Pages (from-to)458-472
Number of pages15
JournalCirculation
Volume139
Issue number4
DOIs
StatePublished - Jan 22 2019

Fingerprint

Percutaneous Coronary Intervention
Registries
Comorbidity
Low-Volume Hospitals
Odds Ratio
Myocardial Infarction
Risk Adjustment
Mortality
Medicare
Hospital Mortality
Emergencies

Keywords

  • morbidity
  • mortality
  • outcome assessment (health care)
  • percutaneous coronary intervention
  • stents

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Fanaroff, A. C., Zakroysky, P., Wojdyla, D., Kaltenbach, L. A., Sherwood, M. W., Roe, M. T., ... Rao, S. V. (2019). Relationship Between Operator Volume and Long-Term Outcomes After Percutaneous Coronary Intervention. Circulation, 139(4), 458-472. https://doi.org/10.1161/CIRCULATIONAHA.117.033325

Relationship Between Operator Volume and Long-Term Outcomes After Percutaneous Coronary Intervention. / Fanaroff, Alexander C.; Zakroysky, Pearl; Wojdyla, Daniel; Kaltenbach, Lisa A.; Sherwood, Matthew W.; Roe, Matthew T.; Wang, Tracy Y.; Peterson, Eric D.; Gurm, Hitinder S.; Cohen, Mauricio G; Messenger, John C.; Rao, Sunil V.

In: Circulation, Vol. 139, No. 4, 22.01.2019, p. 458-472.

Research output: Contribution to journalArticle

Fanaroff, AC, Zakroysky, P, Wojdyla, D, Kaltenbach, LA, Sherwood, MW, Roe, MT, Wang, TY, Peterson, ED, Gurm, HS, Cohen, MG, Messenger, JC & Rao, SV 2019, 'Relationship Between Operator Volume and Long-Term Outcomes After Percutaneous Coronary Intervention', Circulation, vol. 139, no. 4, pp. 458-472. https://doi.org/10.1161/CIRCULATIONAHA.117.033325
Fanaroff AC, Zakroysky P, Wojdyla D, Kaltenbach LA, Sherwood MW, Roe MT et al. Relationship Between Operator Volume and Long-Term Outcomes After Percutaneous Coronary Intervention. Circulation. 2019 Jan 22;139(4):458-472. https://doi.org/10.1161/CIRCULATIONAHA.117.033325
Fanaroff, Alexander C. ; Zakroysky, Pearl ; Wojdyla, Daniel ; Kaltenbach, Lisa A. ; Sherwood, Matthew W. ; Roe, Matthew T. ; Wang, Tracy Y. ; Peterson, Eric D. ; Gurm, Hitinder S. ; Cohen, Mauricio G ; Messenger, John C. ; Rao, Sunil V. / Relationship Between Operator Volume and Long-Term Outcomes After Percutaneous Coronary Intervention. In: Circulation. 2019 ; Vol. 139, No. 4. pp. 458-472.
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abstract = "BACKGROUND: Although many studies show an inverse association between operator procedural volume and short-term adverse outcomes after percutaneous coronary intervention (PCI), the association between procedural volume and longer-term outcomes is unknown. METHODS: Using the National Cardiovascular Data Registry CathPCI registry data linked with Medicare claims data, we examined the association between operator PCI volume and long-term outcomes among patients ≥65 years of age. Operators were stratified by average annual PCI volume (counting PCIs performed in patients of all ages): low- (<50 PCIs), intermediate- (50-100), and high- (>100) volume operators. One-year unadjusted rates of death and major adverse coronary events (MACEs; defined as death, readmission for myocardial infarction, or unplanned coronary revascularization) were calculated with Kaplan-Meier methods. The proportional hazards assumption was not met, and risk-adjusted associations between operator volume and outcomes were calculated separately from the time of PCI to hospital discharge and from hospital discharge to 1-year follow-up. RESULTS: Between July 1, 2009, and December 31, 2014, 723 644 PCI procedures were performed by 8936 operators: 2553 high-, 2878 intermediate-, and 3505 low-volume operators. Compared with high- and intermediate-volume operators, low-volume operators more often performed emergency PCI, and their patients had fewer cardiovascular comorbidities. Over 1-year follow-up, 15.9{\%} of patients treated by low-volume operators had a MACE compared with 16.9{\%} of patients treated by high-volume operators ( P=0.004). After multivariable adjustment, intermediate- and high-volume operators had a significantly lower rate of in-hospital death than low-volume operators (odds ratio, 0.91; 95{\%} CI, 0.86-0.96 for intermediate versus low; odds ratio, 0.79; 95{\%} CI, 0.75-0.83 for high versus low). There were no significant differences in rates of MACEs, death, myocardial infarction, or unplanned revascularization between operator cohorts from hospital discharge to 1-year follow-up (adjusted hazard ratio for MACEs, 0.99; 95{\%} CI, 0.96-1.01 for intermediate versus low; hazard ratio, 1.01; 95{\%} CI, 0.99-1.04 for high versus low). CONCLUSIONS: Unadjusted 1-year outcomes after PCI were worse for older adults treated by operators with higher annual volume; however, patients treated by these operators had more cardiovascular comorbidities. After risk adjustment, higher operator volume was associated with lower in-hospital mortality and no difference in postdischarge MACEs.",
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T1 - Relationship Between Operator Volume and Long-Term Outcomes After Percutaneous Coronary Intervention

AU - Fanaroff, Alexander C.

AU - Zakroysky, Pearl

AU - Wojdyla, Daniel

AU - Kaltenbach, Lisa A.

AU - Sherwood, Matthew W.

AU - Roe, Matthew T.

AU - Wang, Tracy Y.

AU - Peterson, Eric D.

AU - Gurm, Hitinder S.

AU - Cohen, Mauricio G

AU - Messenger, John C.

AU - Rao, Sunil V.

PY - 2019/1/22

Y1 - 2019/1/22

N2 - BACKGROUND: Although many studies show an inverse association between operator procedural volume and short-term adverse outcomes after percutaneous coronary intervention (PCI), the association between procedural volume and longer-term outcomes is unknown. METHODS: Using the National Cardiovascular Data Registry CathPCI registry data linked with Medicare claims data, we examined the association between operator PCI volume and long-term outcomes among patients ≥65 years of age. Operators were stratified by average annual PCI volume (counting PCIs performed in patients of all ages): low- (<50 PCIs), intermediate- (50-100), and high- (>100) volume operators. One-year unadjusted rates of death and major adverse coronary events (MACEs; defined as death, readmission for myocardial infarction, or unplanned coronary revascularization) were calculated with Kaplan-Meier methods. The proportional hazards assumption was not met, and risk-adjusted associations between operator volume and outcomes were calculated separately from the time of PCI to hospital discharge and from hospital discharge to 1-year follow-up. RESULTS: Between July 1, 2009, and December 31, 2014, 723 644 PCI procedures were performed by 8936 operators: 2553 high-, 2878 intermediate-, and 3505 low-volume operators. Compared with high- and intermediate-volume operators, low-volume operators more often performed emergency PCI, and their patients had fewer cardiovascular comorbidities. Over 1-year follow-up, 15.9% of patients treated by low-volume operators had a MACE compared with 16.9% of patients treated by high-volume operators ( P=0.004). After multivariable adjustment, intermediate- and high-volume operators had a significantly lower rate of in-hospital death than low-volume operators (odds ratio, 0.91; 95% CI, 0.86-0.96 for intermediate versus low; odds ratio, 0.79; 95% CI, 0.75-0.83 for high versus low). There were no significant differences in rates of MACEs, death, myocardial infarction, or unplanned revascularization between operator cohorts from hospital discharge to 1-year follow-up (adjusted hazard ratio for MACEs, 0.99; 95% CI, 0.96-1.01 for intermediate versus low; hazard ratio, 1.01; 95% CI, 0.99-1.04 for high versus low). CONCLUSIONS: Unadjusted 1-year outcomes after PCI were worse for older adults treated by operators with higher annual volume; however, patients treated by these operators had more cardiovascular comorbidities. After risk adjustment, higher operator volume was associated with lower in-hospital mortality and no difference in postdischarge MACEs.

AB - BACKGROUND: Although many studies show an inverse association between operator procedural volume and short-term adverse outcomes after percutaneous coronary intervention (PCI), the association between procedural volume and longer-term outcomes is unknown. METHODS: Using the National Cardiovascular Data Registry CathPCI registry data linked with Medicare claims data, we examined the association between operator PCI volume and long-term outcomes among patients ≥65 years of age. Operators were stratified by average annual PCI volume (counting PCIs performed in patients of all ages): low- (<50 PCIs), intermediate- (50-100), and high- (>100) volume operators. One-year unadjusted rates of death and major adverse coronary events (MACEs; defined as death, readmission for myocardial infarction, or unplanned coronary revascularization) were calculated with Kaplan-Meier methods. The proportional hazards assumption was not met, and risk-adjusted associations between operator volume and outcomes were calculated separately from the time of PCI to hospital discharge and from hospital discharge to 1-year follow-up. RESULTS: Between July 1, 2009, and December 31, 2014, 723 644 PCI procedures were performed by 8936 operators: 2553 high-, 2878 intermediate-, and 3505 low-volume operators. Compared with high- and intermediate-volume operators, low-volume operators more often performed emergency PCI, and their patients had fewer cardiovascular comorbidities. Over 1-year follow-up, 15.9% of patients treated by low-volume operators had a MACE compared with 16.9% of patients treated by high-volume operators ( P=0.004). After multivariable adjustment, intermediate- and high-volume operators had a significantly lower rate of in-hospital death than low-volume operators (odds ratio, 0.91; 95% CI, 0.86-0.96 for intermediate versus low; odds ratio, 0.79; 95% CI, 0.75-0.83 for high versus low). There were no significant differences in rates of MACEs, death, myocardial infarction, or unplanned revascularization between operator cohorts from hospital discharge to 1-year follow-up (adjusted hazard ratio for MACEs, 0.99; 95% CI, 0.96-1.01 for intermediate versus low; hazard ratio, 1.01; 95% CI, 0.99-1.04 for high versus low). CONCLUSIONS: Unadjusted 1-year outcomes after PCI were worse for older adults treated by operators with higher annual volume; however, patients treated by these operators had more cardiovascular comorbidities. After risk adjustment, higher operator volume was associated with lower in-hospital mortality and no difference in postdischarge MACEs.

KW - morbidity

KW - mortality

KW - outcome assessment (health care)

KW - percutaneous coronary intervention

KW - stents

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