Effect of Physician and Hospital Experience on Patient Outcomes for Endovascular Treatment of Aortoiliac Occlusive Disease

Indes, Jeffrey; Tuggle, Charles T.; Mandawat, Anant; Muhs, Bart E.; Sosa, Julie Ann

doi:10.1001/archsurg.2011.187

Cited by 17 publications

(12 citation statements)

References 23 publications

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“…27 Our study adds to the previous reports by showing strong inverse relation between hospital volume and mortality/ postprocedural complications after all lower extremity peripheral endovascular interventions that included both angioplasty and stenting. This is important since hospital volume is considered an important proxy for quality in most procedures.…”

Section: Discussionsupporting

confidence: 66%

Impact of Hospital Volume on Outcomes of Lower Extremity Endovascular Interventions (Insights from the Nationwide Inpatient Sample [2006 to 2011])

Arora

Panaich

Patel

et al. 2015

The American Journal of Cardiology

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Section: Discussionsupporting

confidence: 66%

Impact of Hospital Volume on Outcomes of Lower Extremity Endovascular Interventions (Insights from the Nationwide Inpatient Sample [2006 to 2011])

Arora

Panaich

Patel

et al. 2015

The American Journal of Cardiology

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“…The significant relationship between higher procedure volume and improved outcomes—both on a hospital level and a provider level—has been well documented in the endovascular era. 23,24 Although we did not include volume data in our prediction models, worse outcomes were observed in the lower-volume specialty.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of endovascular lower extremity interventions depend more on indication than physician specialty

Wallace

Yuo

Marone

et al. 2014

Journal of Vascular Surgery

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Objective Outcomes of endovascular lower extremity interventions (eLEIs) have been recently linked to provider specialty; however, the indication for intervention was not examined. We sought to compare outcomes between specialties performing eLEI for different indications, in a recent statewide inpatient discharge dataset. Methods The Florida hospital discharge data from 2005 to 2009 were reviewed for patients with LEI during hospitalization. We assigned provider specialty as interventional radiology (IR), interventional cardiology (IC), or vascular surgery (VS) based on provider-associated procedures. Clinical indication was claudication or critical limb ischemia (CLI). We limited our analysis to patients without concomitant open surgery during hospitalization. We compared mortality, length of stay (LOS), major use of intensive care unit (ICU), discharge disposition, and total charges between specialties with regression models, both unadjusted and adjusted for demographic and clinical characteristics. Results A total of 15,398 patients (47% with CLI) had an eLEI. Clinical indication was significantly associated with provider type (P < .001) and outcomes. VS and IR were more likely than IC to treat CLI patients (VS 59%, IR 65%, IC 26%; P < .001). IC performed the majority of procedures on claudicants (VS 30%, IC 57%, IR 13%; P < .001), while VS performed the majority of procedures on CLI patients (VS 50%, IC 23%, IR 27%; P < .001). Adjusted analyses demonstrated no difference in mortality rates between the three specialties (odds ratio [OR] VS: reference, IR: 1.24, IC: 0.79; P = NS for both). However, compared with VS, IR-treated patients were less likely to be discharged home (OR, 0.74; P < .001), LOS was longer (β, 1.16 days; P < .001), major ICU use was more common (OR, 1.49; P < .001), and total charges were higher (β, $341; P = .001). CLI predicted poorer results for all outcomes: death (OR, 4.19; P < .001), discharge home (OR, 0.50; P < .001), increased LOS (β, 3.26 days; P < .001), major ICU use (OR, 1.95; P < .001), and total charges (β, $18,730; P < .001). Conclusions The majority of eLEI done by VS are for CLI, whereas the majority of patients treated by IC are claudicants. Although provider specialty does correlate with several clinical results, the clinical indication for eLEI is a stronger predictor of adverse outcomes. Future analyses of eLEI should adjust for clinical indication.

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“…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. 2,3 Among 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.…”

mentioning

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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Effect of Physician and Hospital Experience on Patient Outcomes for Endovascular Treatment of Aortoiliac Occlusive Disease

Cited by 17 publications

References 23 publications

Impact of Hospital Volume on Outcomes of Lower Extremity Endovascular Interventions (Insights from the Nationwide Inpatient Sample [2006 to 2011])

Impact of Hospital Volume on Outcomes of Lower Extremity Endovascular Interventions (Insights from the Nationwide Inpatient Sample [2006 to 2011])

Outcomes of endovascular lower extremity interventions depend more on indication than physician specialty

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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