Current operator volumes of invasive coronary procedures in medicare patients: Implications for future manpower needs in the catheterization laboratory

Maroney, Justin; Khan, Saba; Powell, Wayne; Klein, Lloyd W.

doi:10.1002/ccd.24366

Cited by 34 publications

(20 citation statements)

References 60 publications

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“…36 Recognizing that 61% of PCI operators in 2008, accounting for 30% of all PCIs performed nationally, performed ≤40 Medicare fee-for-service PCIs argues for the consolidation rather than addition of cardiac catheterization laboratories and for further regionalization of PCI care. 9 Although other studies have shown an inverse relationship between hospital volume and mortality [37][38] , our study is the first meta-analysis to our knowledge to demonstrate a similar association between operator volume and outcomes.…”

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confidence: 45%

“…8 The decreasing clinical requirements for coronary revascularization and the expanding availability of centers offering PCI are likely to cause average facility and operator procedural volumes to decrease dramatically in the future. 9,10 This is of particular relevance, given the adoption of minimal volume standards for competency by several major cardiovascular professional societies. 11 Decreasing average operator volumes may result in an increasing proportion of operators who fall below these minimum standards recommended for competency.…”

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confidence: 99%

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

Strom

Wimmer

Wasfy

et al. 2014

Circ: Cardiovascular Quality and Outcomes

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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.)

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confidence: 45%

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confidence: 99%

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

Strom

Wimmer

Wasfy

et al. 2014

Circ: Cardiovascular Quality and Outcomes

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“…6,16 An additional strength of our study was the comprehensive definition of periprocedural complications accounting for all major post PCIrelated complications similar to previous published analyses. 31 Over the last decade interventional cardiologists have witnessed a decline in the procedural volume 3,4 ( Figures 2 and 3). Some studies have questioned the association between operator/institutional volume and adverse outcome in the current era of technological advancements.…”

Section: Discussionmentioning

confidence: 99%

“…2 The last decade has observed a decline in number of PCIs performed, and many interventional cardiologists have experienced a drop in procedural volume. 3,4 As a result, the Background-The relationship between operator or institutional volume and outcomes among patients undergoing percutaneous coronary interventions (PCI) is unclear. Methods and Results-Cross-sectional study based on the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample between 2005 to 2009.…”

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confidence: 99%

Impact of Annual Operator and Institutional Volume on Percutaneous Coronary Intervention Outcomes

et al. 2014

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1 and the 2011 percutaneous coronary intervention (PCI) guidelines recommend (Class IC) that PCIs should be performed by operators with an annual volume (>75 procedures) at high-volume centers (>400 procedures) with on-site cardiac surgery. 2 The last decade has observed a decline in number of PCIs performed, and many interventional cardiologists have experienced a drop in procedural volume. 3,4 As a result, the Background-The relationship between operator or institutional volume and outcomes among patients undergoing percutaneous coronary interventions (PCI) is unclear. Methods and Results-Cross-sectional study based on the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample between 2005 to 2009. Subjects were identified by International Classification of Diseases, 9 th Revision, Clinical Modification procedure code, 36.06 and 36.07. Annual operator and institutional volumes were calculated using unique identification numbers and then divided into quartiles. Three-level hierarchical multivariate mixed models were created. The primary outcome was in-hospital mortality; secondary outcome was a composite of in-hospital mortality and peri-procedural complications. A total of 457 498 PCIs were identified representing a total of 2 243 209 PCIs performed in the United States during the study period. In-hospital, all-cause mortality was 1.08%, and the overall complication rate was 7.10%. ]. Spline analysis also showed significant operator and institutional volume outcome relationship. Similarly operators in the higher quartiles witnessed a significant reduction in length of hospital stay and cost of hospitalization (P<0.001). Conclusions-Overall in-hospital mortality after PCI was low. An increase in operator and institutional volume of PCI was found to be associated with a decrease in adverse outcomes, length of hospital stay, and cost of hospitalization. 5 These recommendations, however, are based on expert opinion derived from the interpretation of data from multiple sources with inherent limitations. Some of these data were derived from state registries and are dated. 5-24The purpose of this study was to determine the association of annual PCI operator and institutional volume with in-hospital mortality, peri-procedural complications, length of hospital stay, and cost of hospitalization using the nation's largest available all-payer insurance inpatient database in a recent era (2005)(2006)(2007)(2008)(2009)) during which procedural techniques and practices have remained relatively stable. Methods Data SourceWe analyzed 5-year data from the 2005 to 2009 from National Inpatient Sample (NIS) database. The NIS is a subset of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality (AHRQ). The NIS is the largest publicly available all-payer inpatient care database in the United States; including data on approximately 7 to 8 million discharges per year, it is stratified to sample approximately 20% sample of US community (nonfederal, short-term, general, a...

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“…Indeed, a previous analysis of Medicare fee-forservice PCI data reported that a majority (≈61%) of the operators performed <40 PCIs annually. 4 We believe that administrative data sets (eg, NIS and Centers for Medicare & Medicaid Services data) complement NCDR registries. The linkage of CathPCI and other NCDR registries with longitudinal Centers for Medicare & Medicaid Services data has proven to be a quantum leap in outcomes research.…”

Section: 3mentioning

confidence: 99%

Response to Letter Regarding Article “Impact of Annual Operator and Institutional Volume on Percutaneous Coronary Intervention Outcomes: A 5-Year United States Experience (2005–2009)”

et al. 2015

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We appreciate Khera and colleagues for their interest in our study on the percutaneous coronary intervention (PCI) volume-outcome relationship.1 Khera and colleagues point out the limitations of using administrative claims data, some of which we have acknowledged in our article. Despite the inconsistencies and deficiencies in operator identification in the Nationwide Inpatient Sample (NIS) data set, our methodology has been well validated in previous studies. 2,3Among 457 498 PCIs identified in our data set, only 820 procedures (0.2%) were performed in hospitals that reported a single operator. Likewise, the operator volume-outcome relationship did not change in a subgroup analysis by different operator variable identifiers in states that consistently reported unique physician identifiers for the study time period. More than 92% of the procedures identified in our study were listed as primary procedures, highly limiting the possibility of a wrong procedure being linked to the operator.Finally, a direct comparison of median operator volume between NIS and the National Cardiovascular Data Registry (NCDR) CathPCI is not prudent because of differences in representative populations. NIS is designed to approximate a 20% sample of US community hospitals (nonfederal, short-term, general, and specialty), with missing operator volume data on 45% of total PCIs. Registries such as the NCDR CathPCI include operator information for almost all of the PCIs performed in participating hospitals. However, the NIS includes a wealth of administrative data that are not necessarily available in NCDR CathPCI, such as cost of care and concomitant procedures including valvuloplasty and others.The true strength of our study lies in the largest cohort studied to date and reflects the real-world experience of a complex PCI volume-outcome relationship. Our study has greater implications in the current interventional era, where a marked reduction in overall PCI volumes, coupled with a growth of PCI centers in the United States, has led to an overall reduction in PCI procedures at the institutional and operator levels. Indeed, a previous analysis of Medicare fee-forservice PCI data reported that a majority (≈61%) of the operators performed <40 PCIs annually. 4 We believe that administrative data sets (eg, NIS and Centers for Medicare & Medicaid Services data) complement NCDR registries. The linkage of CathPCI and other NCDR registries with longitudinal Centers for Medicare & Medicaid Services data has proven to be a quantum leap in outcomes research. A similar NCDR integration with NIS may offer a multi-insurance outlook. Examination of such administrative data sets provides thought-provoking results that complement the existing literature. The lack of uniform public reporting across the nation will, however, limit the outcomes of any study investigating volume metrics of patient care.We conclude that a strong operator and hospital volume relationship exists in today's world and is backed by preliminary NCDR data. We look forward to further cl...

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Current operator volumes of invasive coronary procedures in medicare patients: Implications for future manpower needs in the catheterization laboratory

Abstract: There is a high percentage of low-volume operators performing PCI, raising questions regarding annual volume recommendations for procedural skill maintenance, and the future manpower requirements in the catheterization laboratory.

Cited by 34 publications

References 60 publications

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

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

Impact of Annual Operator and Institutional Volume on Percutaneous Coronary Intervention Outcomes

Response to Letter Regarding Article “Impact of Annual Operator and Institutional Volume on Percutaneous Coronary Intervention Outcomes: A 5-Year United States Experience (2005–2009)”

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