Outcomes are still associated to operator experience and institutional volume

This study is a retrospective analysis of 2,243,209 PCI stenting procedures in the USA between 2005 and 2009. During this period, a reduction in the number of PCI procedures was observed (also observed globally) from 53 in previous years to 33 procedures per operator per year, and from 1,024 to 693 per hospital per year.

Primary end point was in-hospital mortality and secondary end point was a composite of in-hospital mortality and peri-procedural complications.

Overall in-hospital mortality was 1.08% and peri-procedural complications rate was 7.10%, most common being vascular complications (2.01%), followed by cardiac complications (1.76%), respiratory failure (1.50%) and postoperative stroke (0.99%).

After adjustment for potential confounders, it was observed that In-hospital mortality and peri-procedural complications both increased significantly as PCI volume at operator level declined.

The chance of death or complications doubles among those operators with ≤15 PCIs a year, compared to those with >100 PCIs a year (10.1% vs 5.1% respectively; p<0.001). Operator volume also reduces in-hospital stay and associated costs.

Initially, a similar relationship was observed between outcomes and institutional volume; however, after adjusting by operator volume, the observed difference was considered non-significant.

Conclusion

In-hospital mortality rate in the context of PCI is low. The higher the number of procedures by operator, the lower mortality, complications, in-hospital stay and costs. 

Editorial Comment

Is there a magic number that will turn operators into experts? The last 2013 ACCF/AHA/SCAI issue recommended at least 50 PCIs a year per operator and 200 per center, and this is an amendment to the previous document that had recommended 75 per operator, a reasonable change given the decreasing number of procedures.

The study showed that an important number of operators did not reach the 50 annual procedures, which could be a problem for future PCIs, if this global decreasing tendency continues in the context of a clear relationship between outcomes and volume.

Original title: Impact of annual operator and institutional volume on percutaneous coronary intervention outcomes: a 5-year United States experience (2005-2009). 

Reference: Badheka AO et al. Circulation. 2014; Epub ahead of print.

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