Association Between Operator Procedure Volume and Patient Outcomes in Percutaneous Coronary Intervention

Abstract

Background-The growth of centers capable of performing percutaneous coronary intervention (PCI) has outpaced population growth despite declining incidence of myocardial infarction and prevalence of coronary artery disease, potentially increasing the proportion of operators falling below minimal yearly volume standards set by professional societies. Methods and Results-Electronic literature search of MEDLINE and the Cochrane Library for English-language articles published between 1977 and November 2012 was performed. Title and abstract review followed by full-text and references review were performed by 2 authors independently to identify studies examining the association between operator volume and outcomes in PCI. Using a standardized form, 2 authors abstracted information on study design, methods, outcomes, statistical methods, and conclusions. Studies were categorized according to methodological quality and outcomes. Metaanalyses were performed by outcome using a random-effects model. Of the 23 studies included in the analysis, 14 (61%) evaluated mortality, 7 (30%) evaluated major adverse cardiac events, and 2 (9%) evaluated angiographic success. In total, the studies evaluated 15 907 operators performing 205 214 PCIs on 1 109 103 patients at 2456 centers with a mean follow-up of 2.8 years. Eleven (48%) were considered higher quality. Studies with higher methodological quality and large sample sizes more often showed a relationship between operator volume and outcomes in PCI. Higher volume was associated with improved major adverse cardiac events at every threshold, regardless of the threshold evaluated. Conclusions-Mortality and major adverse cardiac events increase as operator volumes decrease in PCI. Among studies showing a relationship, high-volume operators were defined variably, with annual PCIs ranging from >11 to >270, with no clear evidence of a threshold effect within the ranges studied. (Circ Cardiovasc Qual Outcomes. 2014;7:560-566.)

Stent and Dual Antiplatelet Therapy Duration Comparisons in the Setting of a Multicenter Randomized Controlled Trial: Can the Operator Experience Affect the Study Results?

“…Patients treated by high‐volume operators and at high‐volume centers have been shown to experience a higher rate of procedural success and lower rates of mortality and postprocedural complications 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11. As a consequence, standards of assistance have been recommended for PCI operators 1, 2, 6.…”

“…Although patient‐related factors are known to play a key role for those occurrences, it is currently unknown to which degree these adverse events may be also operator dependent. Overall number of procedures performed and the operator experience may affect outcomes of patients undergoing PCI, but this evidence is mainly based on observational studies 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11. Randomized, controlled trials have played a major role in informing the community on the incidence, predictors, and implications of PCI‐related adverse events.…”

Transcatheter aortic valve implantation. Expert Consensus of the Association of Cardiovascular Interventions of the Polish Cardiac Society and the Polish Society of Cardio-Thoracic Surgeons, approved by the Board of the Polish Cardiac Society…

“…Therefore, interventional cardiologists should take part in courses and practical training in: -interventional treatment of structural heart diseases; -interventional diagnosis and treatment of peripheral artery diseases; -peripheral artery access site management and closure; -extracorporeal membrane oxygenation (ECMO) placement and patient management [13,15,17,18,21,83,90,95,[127][128][129].…”

“…At a minimum, the training should include educational presentations and participation in at least two TAVI procedures performed in a reference TAVI centre [90,95,127,128].…”

The Challenges of Success

“…[13][14][15][16] As a result, minimum volume standards for those physicians performing PCI have been established by multiple professional societies. The 2011 American College of Cardiology Foundation/ American Heart Association/ Society for Cardiovascular Angiography and Interventions (ACCF/AHA/SCAI) clinical competence statement on PCI recommended that PCIs be performed only by operators with an annual volume of >75 procedures at hospitals with an annual volume of >400 procedures.…”