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Kattel S, Tan Z, Lin Z, Mszar R, Sanders P, Zeitler EP, Zei PC, Bunch TJ, Mansour M, Akar J, Curtis JP, Friedman DJ, Freeman JV. Procedural volume and outcomes with atrial fibrillation ablation: A report from the NCDR AFib Ablation Registry. Heart Rhythm 2024:S1547-5271(24)02830-3. [PMID: 38960302 DOI: 10.1016/j.hrthm.2024.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/21/2024] [Accepted: 06/25/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND The association of hospital and physician procedure volume with outcome has not been well evaluated for atrial fibrillation (AF) ablation in contemporary practice. OBJECTIVE This study aimed to determine the association between hospital and physician AF ablation volume and procedural success (isolation of all pulmonary veins) and major adverse events (MAEs). METHODS Procedures reported to the National Cardiovascular Data Registry AFib Ablation Registry between July 2019 and June 2022 were included. Hospital and physician procedural volumes were annualized and stratified into quartiles to compare outcomes. Three-level hierarchical (patient, hospital, and physician) models were used to assess the procedural volume-outcome relationship. RESULTS A total of 70,296 first-time AF ablations at 186 US hospitals were included. Overall, procedural success and MAE rates were 98.5% and 1.0%, respectively. With hospital volume (Q4) as a reference, the likelihood of procedural success was lower for Q1 (odds ratio [OR], 0.44; 95% CI, 0.29-0.68), Q2 (OR, 0.50; 95% CI, 0.33-0.75), and Q3 (OR, 0.60; 95% CI, 0.40-0.89); the results were similarly significant for physician volume. With MAE for hospitals, there was an inverse procedural volume relationship for Q1 (OR, 1.78; 95% CI, 1.26-2.52) but not for Q2 (OR, 1.06; 95% CI, 0.77-1.46) or Q3 (OR, 1.19; 95% CI, 0.89-1.58) and similarly for physicians in Q1 and Q2 but not in Q3. An adjusted MAE ≤1% was predicted by an annual volume of approximately 190 for hospitals and 60 for physicians. CONCLUSION In this national cohort, hospital and physician AF ablation procedural volumes were directly related to acute procedural success and inversely related to rates of MAE.
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Affiliation(s)
- Sharma Kattel
- Department of Medicine, University of Minnesota/Minneapolis VAMC, Minneapolis, Minnesota.
| | - Zhen Tan
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
| | - Reed Mszar
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Emily P Zeitler
- Dartmouth Health and The Dartmouth Institute, Lebanon, New Hampshire
| | - Paul C Zei
- Brigham and Women's Hospital, Boston, Massachusetts
| | - T Jared Bunch
- University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Joseph Akar
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - James V Freeman
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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2
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Friedman DJ, Du C, Zimmerman S, Tan Z, Lin Z, Vemulapalli S, Kosinski A, Piccini JP, Pereira L, Minges KE, Faridi KF, Masoudi FA, Curtis JP, Freeman JV. Procedure Volume and Outcomes With WATCHMAN Left Atrial Appendage Occlusion. Circ Cardiovasc Interv 2024; 17:e013466. [PMID: 38889251 PMCID: PMC11189610 DOI: 10.1161/circinterventions.123.013466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/27/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Procedure volumes are associated with outcomes for many cardiovascular procedures, leading to guidelines on minimum volume thresholds for certain procedures; however, the volume-outcome relationship with left atrial appendage occlusion is poorly understood. As such, we sought to determine the relationship between hospital and physician volume and WATCHMAN left atrial appendage occlusion procedural success overall and with the new generation WATCHMAN FLX device. METHODS We performed an analysis of WATCHMAN procedures (January 2019 to October 2021) from the National Cardiovascular Data Registry LAAO Registry. Three-level hierarchical generalized linear models were used to assess the adjusted relationship between procedure volume and procedural success (device released with peridevice leak <5 mm, no in-hospital major adverse events). RESULTS Among 87 480 patients (76.2±8.0 years; 58.8% men; mean CHA2DS2-VASc score, 4.8±1.5) from 693 hospitals, the procedural success rate was 94.2%. With hospital volume Q4 (greatest volume) as the reference, the likelihood of procedural success was significantly less among Q1 (odds ratio [OR], 0.66 [CI, 0.57-0.77]) and Q2 (OR, 0.78 [CI, 0.69-0.90]) but not Q3 (OR, 0.95 [CI, 0.84-1.07]). With physician volume Q4 (greatest volume) as the reference, the likelihood of procedural success was significantly less among Q1 (OR, 0.72 [CI, 0.63-0.82]), Q2 (OR, 0.79 [CI, 0.71-0.89]), and Q3 (OR, 0.88 [CI, 0.79-0.97]). Among WATCHMAN FLX procedures, there was attenuation of the volume-outcome relationships, with statistically significant but modest absolute differences of only ≈1% across volume quartiles. CONCLUSIONS In this contemporary national analysis, greater hospital and physician WATCHMAN volumes were associated with increased procedure success. The WATCHMAN FLX transition was associated with increased procedural success and less heterogeneity in outcomes across volume quartiles. These findings indicate the importance of understanding the volume-outcome relationship for individual left atrial appendage occlusion devices.
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Affiliation(s)
- Daniel J. Friedman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Chengan Du
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
| | - Sarah Zimmerman
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
| | - Zhen Tan
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
| | | | - Andrzej Kosinski
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Jonathan P. Piccini
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Lucy Pereira
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
| | - Karl E. Minges
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Department of Population Health and Leadership, University of New Haven, West Haven, CT, USA
| | - Kamil F. Faridi
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - James V. Freeman
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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3
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Oettinger V, Hehn P, Bode C, Zehender M, von zur Mühlen C, Westermann D, Stachon P, Kaier K. Center Volumes Correlate with Likelihood of Stent Implantation in German Coronary Angiography. J Interv Cardiol 2023; 2023:3723657. [PMID: 38028025 PMCID: PMC10653957 DOI: 10.1155/2023/3723657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 10/15/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Aims Literature on percutaneous coronary intervention (PCI) stated an inverse relationship between hospital volume and mortality, but the effects on other characteristics are unclear. Methods Using German national records, all coronary angiographies with coronary artery disease in 2017 were identified. We applied risk-adjustment to account for differences in population characteristics. Results Of overall 528,188 patients, 55.22% received at least one stent, with on average 1.01 stents implanted in all patients. Based on those patients who received at least one stent, this corresponds to an average number of 1.82 stents. In-hospital mortality across all patients was 2.93%, length of hospital stay was 6.46 days, and mean reimbursement was €5,531. There were comparatively more emergency admissions in low volume centers and more complex cases (3-vessel disease, left main stenosis, and in-stent stenosis) in high volume centers. In multivariable regression analysis, volume and likelihood of stent implantation (p=0.003) as well as number of stents (p=0.020) were positively correlated. No relationship was seen for in-hospital mortality (p=0.105), length of stay (p=0.201), and reimbursement (p=0.108). Nonlinear influence of volume suggests a ceiling effect: In hospitals with ≤100 interventions, likelihood and number of implanted stents are lowest (∼34% and 0.6). After that, both rise steadily until a volume of 500 interventions. Finally, both remain stable in the categories of over 500 interventions (∼60% and 1.1). Conclusion In PCI, lower volume centers contribute to emergency care. Higher volume centers treat more complex cases and show a higher likelihood of stent implantations, with a stable safety.
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Affiliation(s)
- Vera Oettinger
- Department of Cardiology and Angiology, University Heart Center, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philip Hehn
- Institute of Medical Biometry and Statistics, Faculty of Medicine, Medical Center–University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology, University Heart Center, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Department of Cardiology and Angiology, University Heart Center, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von zur Mühlen
- Department of Cardiology and Angiology, University Heart Center, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Department of Cardiology and Angiology, University Heart Center, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Medical Biometry and Statistics, Faculty of Medicine, Medical Center–University of Freiburg, Freiburg, Germany
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4
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Romano LR, Spaccarotella CAM, Indolfi C, Curcio A. Revascularization and Left Ventricular Dysfunction for ICD Eligibility. Life (Basel) 2023; 13:1940. [PMID: 37763344 PMCID: PMC10533106 DOI: 10.3390/life13091940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/17/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Common triggers for sudden cardiac death (SCD) are transient ischemia, hemodynamic fluctuations, neurocardiovascular influences, and environmental factors. SCD occurs rapidly when sinus rhythm degenerates into ventricular tachycardia (VT) and/or ventricular fibrillation (VF), followed by asystole. Such progressive worsening of the cardiac rhythm is in most cases observed in the setting of ischemic heart disease and often associated with advanced left ventricular (LV) impairment. Revascularization prevents negative outcomes including SCD and heart failure (HF) due to LV dysfunction (LVD). The implantable cardioverter-defibrillator (ICD) on top of medical therapy is superior to antiarrhythmic drugs for patients with LVD and VT/VF. The beneficial effects of ICD have been demonstrated in primary prevention of SCD as well. However, yet debated is the temporal management for patients with LVD who are eligible to ICD prior to revascularization, either through percutaneous or surgical approach. Restoration of coronary blood flow has a dramatic impact on adverse LV remodeling, while it requires aggressive long-term antiplatelet therapy, which might increase complication for eventual ICD procedure when percutaneous strategy is pursued; on the other hand, when LV and/or multiorgan dysfunction is present and coronary artery bypass grafting is chosen, the overall risk is augmented, mostly in HF patients. The aims of this review are to describe the pathophysiologic benefits of revascularization, the studies addressing percutaneous, surgical or no revascularization and ICD implantation, as well as emerging defibrillation strategies for patients deemed at transient risk of SCD and/or at higher risk for transvenous ICD implantation.
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Affiliation(s)
- Letizia Rosa Romano
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | | | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
| | - Antonio Curcio
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy
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5
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Kim JY, Kang J, Kim BJ, Kim SE, Kim DY, Lee KJ, Park HK, Cho YJ, Park JM, Lee KB, Cha JK, Lee JS, Lee J, Yang KH, Hong OR, Shin JH, Park JH, Gorelick PB, Bae HJ. Annual Case Volume and One-Year Mortality for Endovascular Treatment in Acute Ischemic Stroke. J Korean Med Sci 2022; 37:e270. [PMID: 36123959 PMCID: PMC9485065 DOI: 10.3346/jkms.2022.37.e270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/21/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The association between endovascular treatment (EVT) case volume per hospital and clinical outcomes has been reported, but the exact volume threshold has not been determined. This study aimed to examine the case volume threshold in this context. METHODS National audit data on the quality of acute stroke care in patients admitted via emergency department, within 7 days of onset, in hospitals that treated ≥ 10 stroke cases during the audit period were analyzed. Ischemic stroke cases treated with EVT during the last three audits (2013, 2014, and 2016) were selected for the analysis. Annual EVT case volume per hospital was estimated and analyzed as a continuous and a categorical variable (in quartiles). The primary outcome measure was 1-year mortality as a surrogate of 3-month functional outcome. As post-hoc sensitivity analysis, replication of the study results was examined using the 2018 audit data. RESULTS We analyzed 1,746 ischemic stroke cases treated with EVT in 120 acute care hospitals. The median annual EVT case volume was 12.0 cases per hospital, and mortality rates at 1 month, 3 months, and 1 year were 12.7%, 16.6%, and 23.3%, respectively. Q3 and Q4 had 33% lower odds of 1-year mortality than Q1. Adjustments were made for predetermined confounders. Annual EVT case volume cut-off value for 1-year mortality was 15 cases per year (P < 0.02). The same cut-off value was replicated in the sensitivity analysis. CONCLUSION Annual EVT case volume was associated with 1-year mortality. The volume threshold per hospital was 15 cases per year.
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Affiliation(s)
- Jun Yup Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jihoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seong-Eun Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Do Yeon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Keon-Joo Lee
- Department of Neurology, Korea University Guro Hospital, Seoul, Korea
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Ki Hwa Yang
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Ock Ran Hong
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Ji Hyeon Shin
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Jung Hyun Park
- Department of Neurology, Gyeonggi Provincial Medical Center Icheon Hospital, Icheon, Korea
| | - Philip B Gorelick
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
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6
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Witberg G, Landes U, Talmor-Barkan Y, Richter I, Barbanti M, Valvo R, De Backer O, Ooms JF, Islas F, Marroquin L, Sedaghat A, Sugiura A, Masiero G, Armario X, Fiorina C, Arzamendi D, Santos-Martinez S, Fernández-Vázquez F, Baz JA, Steblovnik K, Mauri V, Adam M, Merdler I, Hein M, Ruile P, Codner P, Grasso C, Branca L, Estévez-Loureiro R, Benito-González T, Amat-Santos IJ, Mylotte D, Bunc M, Tarantini G, Nombela-Franco L, Søndergaard L, Van Mieghem NM, Finkelstein A, Kornowski R. Center Valve Preference and Outcomes of Transcatheter Aortic Valve Replacement: Insights From the AMTRAC Registry. JACC Cardiovasc Interv 2022; 15:1266-1274. [PMID: 35738747 DOI: 10.1016/j.jcin.2022.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/25/2022] [Accepted: 05/03/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Data on outcomes of transcatheter aortic valve replacement (TAVR) using balloon-expandable valves (BEVs) or self-expandable valves (SEVs) as well as the impact of center valve preference on these outcomes are limited. OBJECTIVES The aim of this study was to compare outcomes of TAVR procedures using third-generation BEVs and SEVs stratified by center valve preference. METHODS In a multicenter registry (n = 17), 13 centers exhibited valve preference (66.6%-90% of volume) and were included. Outcomes were compared between BEVs and SEVs stratified by center valve preference. RESULTS In total, 7,528 TAVR procedures (3,854 with SEVs and 3,674 with BEVs) were included. The mean age was 81 years, and the mean Society of Thoracic Surgeons score was 5.2. Baseline characteristics were similar between BEVs and SEVs. Need for pacemaker implantation was higher with SEVs at BEV- and SEV-dominant centers (17.8% vs 9.3% [P < 0.001] and 12.7% vs 10.0% [P = 0.036], respectively; HR: 1.51; P for interaction = 0.021), risk for cerebrovascular accident was higher with SEVs at BEV-dominant but not SEV-dominant centers (3.6% vs 1.1% [P < 0.001] and 2.2% vs 1.4% [P = 0.162]; HR: 2.08; P for interaction < 0.01). Aortic regurgitation greater than mild was more frequent with SEVs at BEV-dominant centers and similar with BEVs regardless of center dominance (5.2% vs 2.8% [P < 0.001] and 3.4% vs 3.7% [P = 0.504], respectively). Two-year mortality was higher with SEVs at BEV-dominant centers but not at SEV-dominant centers (21.9% vs 16.9% [P = 0.021] and 16.8% vs 16.5% [P = 0.642], respectively; HR: 1.20; P for interaction = 0.032). CONCLUSIONS Periprocedural outcomes, aortic regurgitation greater than mild, and 2-year mortality are worse when TAVR is performed using SEVs at BEV-dominant centers. Outcomes are similar regardless of valve type at SEV-dominant centers. The present results stress the need to account for this factor when comparing BEV and SEV outcomes. (The Aortic+Mitral Transcatheter [AMTRAC] Valve Registry; NCT04031274).
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Affiliation(s)
- Guy Witberg
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Uri Landes
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of Cardiology, Wolfson Medical Center, Holon, Israel
| | - Yeela Talmor-Barkan
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ilan Richter
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Marco Barbanti
- Division of Cardiology, University of Catania, Catania, Italy
| | - Roberto Valvo
- Division of Cardiology, University of Catania, Catania, Italy
| | - Ole De Backer
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Joris F Ooms
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Fabian Islas
- Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Luis Marroquin
- Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | | | | | - Giulia Masiero
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Xavier Armario
- Department of Cardiology, Galway University Hospital, and National University of Ireland Galway, Galway, Ireland
| | | | - Dabit Arzamendi
- Hospital de Sant Creu i Sant Pau Barcelona, Barcelona, Spain
| | | | | | - Jose A Baz
- Servicio de Cardiología, Hospital Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Klemen Steblovnik
- Department of Cardiology, University Medical Center, Ljubljana, Slovenia
| | - Victor Mauri
- Department of Cardiology, Heart Center, Faculty of Medicine, University of Cologne, Germany
| | - Matti Adam
- Department of Cardiology, Heart Center, Faculty of Medicine, University of Cologne, Germany
| | - Ilan Merdler
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Manuel Hein
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Philipp Ruile
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Pablo Codner
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Carmelo Grasso
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of Cardiology, Wolfson Medical Center, Holon, Israel
| | - Luca Branca
- Cardiovascular Department, Spedali Civili, Brescia, Italy
| | | | | | | | - Darren Mylotte
- Department of Cardiology, Galway University Hospital, and National University of Ireland Galway, Galway, Ireland
| | - Matjaz Bunc
- Department of Cardiology, University Medical Center, Ljubljana, Slovenia
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Lars Søndergaard
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ariel Finkelstein
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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7
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Schrage B, Zeymer U, Montalescot G, Windecker S, Serpytis P, Vrints C, Stepinska J, Savonitto S, Oldroyd KG, Desch S, Fuernau G, Huber K, Noc M, Schneider S, Ouarrak T, Blankenberg S, Thiele H, Clemmensen P. Impact of Center Volume on Outcomes in Myocardial Infarction Complicated by Cardiogenic Shock: A CULPRIT-SHOCK Substudy. J Am Heart Assoc 2021; 10:e021150. [PMID: 34622680 PMCID: PMC8751884 DOI: 10.1161/jaha.120.021150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background Little is known about the impact of center volume on outcomes in acute myocardial infarction complicated by cardiogenic shock. The aim of this study was to investigate the association between center volume, treatment strategies, and subsequent outcome in patients with acute myocardial infarction complicated by cardiogenic shock. Methods and Results In this subanalysis of the randomized CULPRIT‐SHOCK (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock) trial, study sites were categorized based on the annual volume of acute myocardial infarction complicated by cardiogenic shock into low‐/intermediate‐/high‐volume centers (<50; 50–100; and >100 cases/y). Subjects from the study/compulsory registry with available volume data were included. Baseline/procedural characteristics, overall treatment, and 1‐year all‐cause mortality were compared across categories. n=1032 patients were included in this study (537 treated at low‐volume, 240 at intermediate‐volume, and 255 at high‐volume centers). Baseline risk profile of patients across the volume categories was similar, although high‐volume centers included a larger number of older patients. Low‐/intermediate‐volume centers had more resuscitated patients (57.5%/58.8% versus 42.2%; P<0.01), and more patients on mechanical ventilation in comparison to high‐volume centers. There were no differences in reperfusion success despite considerable differences in adjunctive pharmacological/device therapies. There was no difference in 1‐year all‐cause mortality across volume categories (51.1% versus 56.5% versus 54.4%; P=0.34). Conclusions In this study of patients with acute myocardial infarction complicated by cardiogenic shock, considerable differences in adjunctive medical and mechanical support therapies were observed. However, we could not detect an impact of center volume on reperfusion success or mortality.
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Affiliation(s)
- Benedikt Schrage
- Department of Cardiology University Heart and Vascular Centre Hamburg Hamburg Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck Hamburg Germany
| | - Uwe Zeymer
- Department of Cardiology Klinikum der Stadt Ludwigshafen Ludwigshafen am Rhein Germany
| | - Gilles Montalescot
- Sorbonne UniversityACTION Study GroupINSERM UMRS 1166Institut de CardiologieHôpital Pitié-Salpêtrière (AP-HP) Paris France
| | - Stephan Windecker
- Department of Cardiology Bern University HospitalInselspitalUniversity of Bern Bern Switzerland
| | - Pranas Serpytis
- Clinic of Emergency Medicine Faculty of Medicine VIilnius University Lithuania
| | | | - Janina Stepinska
- Department of the Intensive Cardiac Therapy National Institute of Cardiology Warsaw Poland
| | | | - Keith G Oldroyd
- West of Scotland Regional Heart and Lung Centre Golden Jubilee National Hospital Glasgow United Kingdom
| | - Steffen Desch
- Department of Internal Medicine/Cardiology Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute Leipzig Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck Luebeck Germany
| | - Georg Fuernau
- Medical Clinic II (Cardiology, Angiology Intensive Care Medicine) University Heart Center Luebeck Luebeck Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck Luebeck Germany
| | - Kurt Huber
- 3rd Department of Medicine Cardiology and Intensive Care Medicine Wilhelminenhospital and Sigmund Freud UniversityMedical Faculty Vienna Austria
| | - Marko Noc
- Center for Intensive Internal MedicineUniversity Medical Center Ljubljana Slovenia
| | - Steffen Schneider
- Stiftung Institut für Herzinfarktforschung Ludwigshafen am Rhein Germany
| | - Taoufik Ouarrak
- Stiftung Institut für Herzinfarktforschung Ludwigshafen am Rhein Germany
| | - Stefan Blankenberg
- Department of Cardiology University Heart and Vascular Centre Hamburg Hamburg Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck Hamburg Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute Leipzig Germany
| | - Peter Clemmensen
- Department of Cardiology University Heart and Vascular Centre Hamburg Hamburg Germany.,Department of Regional Research and Department of Medicine Faculty of Health Sciences Nykoebing F HospitalUniversity of Southern Denmark Odense Denmark
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8
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Gurm HS, Sukul D. Drilling Down to Quality: Rotational Atherectomy, Operator Volume, and PCI Outcomes. JACC Cardiovasc Interv 2021; 14:1431-1433. [PMID: 34147379 DOI: 10.1016/j.jcin.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 05/13/2021] [Indexed: 12/30/2022]
Affiliation(s)
- Hitinder S Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| | - Devraj Sukul
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
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9
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Walsh KA, Plunkett T, O'Brien KK, Teljeur C, Smith SM, Harrington P, Ryan M. The relationship between procedural volume and patient outcomes for percutaneous coronary interventions: a systematic review and meta-analysis. HRB Open Res 2021; 4:10. [PMID: 33842830 PMCID: PMC8008355 DOI: 10.12688/hrbopenres.13203.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The relationship between procedural volume and outcomes for percutaneous coronary interventions (PCI) is contentious, with previous reviews suggesting an inverse volume-outcome relationship. The aim of this study was to systematically review contemporary evidence to re-examine this relationship. METHODS A systematic review and meta-analysis was undertaken to examine the relationship between PCI procedural volume (both at hospital- and operator-levels) and outcomes in adults. The primary outcome was mortality. The secondary outcomes were complications, healthcare utilisation and process outcomes. Searches were conducted from 1 January 2008 to 28 May 2019. Certainty of the evidence was assessed using 'Grading of Recommendations, Assessment, Development and Evaluations' (GRADE). Screening, data extraction, quality appraisal and GRADE assessments were conducted independently by two reviewers. RESULTS Of 1,154 unique records retrieved, 22 observational studies with 6,432,265 patients were included. No significant association was found between total PCI hospital volume and mortality (odds ratio [OR]: 0.84, 95% confidence interval [CI]: 0.69-1.03, I 2 = 86%). A temporal trend from significant to non-significant pooled effect estimates was observed. The pooled effect estimate for mortality was found to be significantly in favour of high-volume operators for total PCI procedures (OR: 0.77, 95% CI: 0.63-0.94, I 2 = 93%), and for high-volume hospitals for primary PCI procedures (OR: 0.77, 95% CI: 0.62-0.94, I 2 = 78%). Overall, GRADE certainty of evidence was 'very low'. There were mixed findings for secondary outcomes. CONCLUSIONS A volume-outcome relationship may exist in certain situations, although this relationship appears to be attenuating with time, and there is 'very low' certainty of evidence. While volume might be important, it should not be the only standard used to define an acceptable PCI service and a broader evaluation of quality metrics should be considered that encompass patient experience and clinical outcomes. Systematic review registration: PROSPERO, CRD42019125288.
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Affiliation(s)
- Kieran A. Walsh
- Health Technology Assessment (HTA) Directorate, Health Information and Quality Authority, Dublin 7, Ireland
| | - Thomas Plunkett
- Health Technology Assessment (HTA) Directorate, Health Information and Quality Authority, Dublin 7, Ireland
| | - Kirsty K. O'Brien
- Health Technology Assessment (HTA) Directorate, Health Information and Quality Authority, Dublin 7, Ireland
| | - Conor Teljeur
- Health Technology Assessment (HTA) Directorate, Health Information and Quality Authority, Dublin 7, Ireland
| | - Susan M. Smith
- Health Research Board Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Patricia Harrington
- Health Technology Assessment (HTA) Directorate, Health Information and Quality Authority, Dublin 7, Ireland
| | - Máirín Ryan
- Health Technology Assessment (HTA) Directorate, Health Information and Quality Authority, Dublin 7, Ireland
- Department of Pharmacology & Therapeutics, Trinity College Dublin, Dublin 8, Ireland
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10
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Stein LK, Tuhrim S, Jette N, Fifi J, Mocco J, Dhamoon MS. Nationwide Analysis of Endovascular Thrombectomy Provider Specialization for Acute Stroke. Stroke 2020; 51:3651-3657. [DOI: 10.1161/strokeaha.120.029989] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background and Purpose:
Determine the extent of cerebrovascular expertise among the specialties of proceduralists providing endovascular thrombectomy (ET) for emergent large vessel occlusion stroke in the modern era of acute stroke among Medicare beneficiaries
Methods:
Retrospective cohort study using validated
International Classification of Diseases, Tenth Revision
, Clinical Modification codes to identify admissions with acute ischemic stroke and treatment with ET. We identified proceduralist specialty by linking the National Provider Identifier provided by Medicare to the specialty listed in the National Provider Identifier database, grouping into radiology, neurology, neurosurgery, other surgical, and internal medicine. We calculated the number of proceduralists and hospitals who performed ET, ET team specialty composition by hospital, and number of proceduralists who performed ET at multiple hospitals.
Results:
Forty-two percent (n=5612) of ET were performed by radiology-background proceduralists, with unclear knowledge of how many were cerebrovascular specialists. Neurosurgery- and neurology-background interventionalists performed fewer but substantial numbers of cases, accounting for 24% (n=3217) and 23% (n=3124) of total cases, respectively. ET teams included a neurology- or neurosurgery-background proceduralist at 65% (n=407) of hospitals that performed ET and included both in 26% (n=160) of teams.
Conclusions:
Almost two-thirds of ET teams nationwide include a neurology- or neurosurgery-background proceduralist and higher volume centers in urban areas were more likely to have neurology- or neurosurgery-background proceduralists with cerebrovascular expertise on their team. It is unclear how many radiology-background interventionalists are cerebrovascular specialists versus generalists. Significant work remains to be done to understand the impact of proceduralist specialty, training, and cerebrovascular expertise on ET outcomes.
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Affiliation(s)
- Laura K. Stein
- Department of Neurology (L.K.S., S.T., N.J., J.F., M.S.D.), Icahn School of Medicine at Mount Sinai, NY
| | - Stanley Tuhrim
- Department of Neurology (L.K.S., S.T., N.J., J.F., M.S.D.), Icahn School of Medicine at Mount Sinai, NY
| | - Nathalie Jette
- Department of Neurology (L.K.S., S.T., N.J., J.F., M.S.D.), Icahn School of Medicine at Mount Sinai, NY
| | - Johanna Fifi
- Department of Neurology (L.K.S., S.T., N.J., J.F., M.S.D.), Icahn School of Medicine at Mount Sinai, NY
- Department of Neurosurgery (J.F., J.M.), Icahn School of Medicine at Mount Sinai, NY
| | - J Mocco
- Department of Neurosurgery (J.F., J.M.), Icahn School of Medicine at Mount Sinai, NY
| | - Mandip S. Dhamoon
- Department of Neurology (L.K.S., S.T., N.J., J.F., M.S.D.), Icahn School of Medicine at Mount Sinai, NY
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11
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Yamaji K, Kohsaka S, Inohara T, Numasawa Y, Ishii H, Amano T, Ikari Y. Population Density Analysis of Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction in Japan. J Am Heart Assoc 2020; 9:e016952. [PMID: 32720569 PMCID: PMC7792283 DOI: 10.1161/jaha.120.016952] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Despite recent progress in the treatment of ST‐segment–elevation myocardial infarction, data on geographic disparities application of the evidence‐based therapy remain limited. Methods and Results The J‐PCI (Japanese Percutaneous Coronary Intervention) registry is a nationwide registry to assure the quality of delivered care. Between January 2014 and December 2018, 209 521 patients underwent percutaneous coronary intervention for ST‐segment–elevation myocardial infarction in 1126 institutions. The patients were divided into tertiles according to the population density (PD) of the percutaneous coronary intervention institution location (low: <951.7/km2, n = 69 797; medium: 951.7–4729.7/km2, n = 69 750; high: ≥4729.7/km2, n = 69 974). Patients treated in high PD administrative districts were younger and more likely to be male. No significant correlation was observed between PD and door‐to‐balloon time (regression coefficients: 0.036 per 1000 people/km2; 95% CI, −0.232 to 0.304; P = 0.79). Patients treated in low‐PD areas had higher crude in‐hospital mortality rates than those treated in high‐PD areas (low: 2.89%; medium: 2.60%; high: 2.38%; P < 0.001); PD and in‐hospital mortality had a significantly inverse association, before and after adjusting for baseline characteristics (crude odds ratio [OR], 0.983 per 1000/km2; 95% CI, 0.973–0.992; P < 0.001; adjusted OR, 0.980 per 1000/km2; 95% CI, 0.964–0.996; P = 0.01, respectively). Higher‐PD districts had more operators per institution (low: 6; interquartile range, 3–10; medium: 7; IQR, 3–13; high: 8; IQR, 5–13; P < 0.001), suggesting an inverse association with in‐hospital mortality (OR, 0.992; 95% CI, 0.986–0.999; P = 0.03). Conclusions Geographic inequality was observed in in‐hospital mortality of patients with ST‐segment–elevation myocardial infarction who underwent percutaneous coronary intervention. Variation in the number of operators per institution, rather than traditional quality indicators (eg, door‐to‐balloon time) might explain the difference in in‐hospital mortality.
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Affiliation(s)
- Kyohei Yamaji
- Division of Cardiology Kokura Memorial Hospital Kitakyushu Japan
| | - Shun Kohsaka
- Department of Cardiology Keio University School of Medicine Tokyo Japan
| | - Taku Inohara
- Department of Cardiology Keio University School of Medicine Tokyo Japan.,Division of Cardiology Vancouver General Hospital British Columbia Canada
| | - Yohei Numasawa
- Department of Cardiology Japanese Red Cross Ashikaga Hospital Ashikaga Japan
| | - Hideki Ishii
- Department of Cardiology Fujita Health University Bantane Hospital Nagoya Japan
| | - Tetsuya Amano
- Department of Cardiology Aichi Medical University Aichi Japan
| | - Yuji Ikari
- Department of Cardiology Tokai University School of Medicine Kanagawa Japan
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12
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Becher PM, Goßling A, Schrage B, Twerenbold R, Fluschnik N, Seiffert M, Bernhardt AM, Reichenspurner H, Blankenberg S, Westermann D. Procedural volume and outcomes in patients undergoing VA-ECMO support. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:291. [PMID: 32503646 PMCID: PMC7275456 DOI: 10.1186/s13054-020-03016-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/25/2020] [Indexed: 01/11/2023]
Abstract
Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in patients with critical cardiopulmonary failure. To investigate the association between hospital VA-ECMO procedure volume and outcomes in a large, nationwide registry. Methods By using administrative data from the German Federal Health Monitoring System, we analyzed all VA-ECMO procedures performed in Germany from 2013 to 2016 regarding the association of procedural volumes with outcomes and complications. Results During the study period, 10,207 VA-ECMO procedures were performed; mean age was 61 years, 43.4% had prior CPR, and 71.2% were male patients. Acute coronary syndrome was the primary diagnosis for VA-ECMO implantation (n = 6202, 60.8%). The majority of implantations (n = 5421) were performed at hospitals in the lowest volume category (≤ 50 implantations per year). There was a significant association between annualized volume of VA-ECMO procedures and 30-day in-hospital mortality for centers with lower vs. higher volume per year. Multivariable logistic regression showed an increased 30-day in-hospital mortality at hospitals with the lowest volume category (adjusted odds ratio 1.13, 95% confidence interval [CI] 1.01–1.27, p = 0.034). Similarly, higher likelihood for complications was observed at hospitals with lower vs. higher annual VA-ECMO volume (adjusted odds ratio 1.46, 95% CI 1.29–1.66, p = 0.001). Conclusions In this analysis of more than 10,000 VA-ECMO procedures for cardiogenic shock, the majority of implantations were performed at hospitals with the lowest annual volume. Thirty-day in-hospital mortality and likelihood for complications were higher at hospitals with the lowest annual VA-ECMO volume.
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Affiliation(s)
- Peter Moritz Becher
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Alina Goßling
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nina Fluschnik
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Moritz Seiffert
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany. .,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.
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13
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The Relation between Volume and Outcome of Transcatheter and Surgical Aortic Valve Replacement: A Systematic Review and Meta-Analysis. Cardiovasc Ther 2020; 2020:2601340. [PMID: 32395180 PMCID: PMC7189304 DOI: 10.1155/2020/2601340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/25/2020] [Accepted: 03/12/2020] [Indexed: 12/25/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) are standard procedures for dealing with severe aortic stenosis patients. Researchers have not carried out a systematic review of the volume-outcome relationship in TAVR and SAVR. Our study is intended to address this problem. We systemically searched databases through MEDLINE, EMBASE, PUBMED, and the Cochrane Library up to September 2019. Two reviewers independently screened for the studies and evaluated bias. We used short-term mortality (in-hospital or 30-day mortality) as an outcome. A meta-analysis of TAVR with 115,596 patients ranging from 2005 to 2016 showed a result significantly in favor of high-volume hospitals (OR 0.43 (CI 0.36-0.51)). The subgroup of population period, region, data type, and cut-off value did not show any difference. A meta-analysis of SAVR comprising 418,384 patients ranging from 1994 to 2011 revealed that the OR of short-term mortality for a high-volume hospital compared with that of a low-volume hospital was 0.73 (CI 0.71, 0.74). No difference was observed in subgroups based on population period and cut-off. In conclusion, we found that short-term mortality was lower in high-volume hospitals for both TAVR and SAVR.
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14
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Valle JA, Tamez H, Abbott JD, Moussa ID, Messenger JC, Waldo SW, Kennedy KF, Masoudi FA, Yeh RW. Contemporary Use and Trends in Unprotected Left Main Coronary Artery Percutaneous Coronary Intervention in the United States: An Analysis of the National Cardiovascular Data Registry Research to Practice Initiative. JAMA Cardiol 2020; 4:100-109. [PMID: 30601910 DOI: 10.1001/jamacardio.2018.4376] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Recent data support percutaneous revascularization as an alternative to coronary artery bypass grafting in unprotected left main (ULM) coronary lesions. However, the relevance of these trials to current practice is unclear, as patterns and outcomes of ULM percutaneous coronary intervention (PCI) in contemporary US clinical practice are not well studied. Objective To define the current practice of ULM PCI and its outcomes and compare these with findings reported in clinical trials. Design, Setting, and Participants This cross-sectional multicenter analysis included data collected from 1662 institutions participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry between April 2009 and July 2016. Data were collected from 33 128 patients undergoing ULM PCI and 3 309 034 patients undergoing all other PCI. Data were analyzed from June 2017 to May 2018. Main Outcomes and Measures Patient and procedural characteristics and their temporal trends were compared between ULM PCI and all other PCI. In-hospital major adverse clinical events (ie, death, myocardial infarction, stroke, and emergent coronary artery bypass grafting) were compared using hierarchical logistic regression. Characteristics and outcomes were also compared against clinical trial cohorts. Results Of the 3 342 162 included patients, 2 223 570 (66.5%) were male, and the mean (SD) age was 64.2 (12.1) years. Unprotected left main PCI represented 1.0% (33 128 of 3 342 162) of all procedures, modestly increasing from 0.7% to 1.3% over time. The mean (SD) annualized ULM PCI volume was 0.5 (1.5) procedures for operators and 3.2 (6.1) procedures for facilities, with only 1808 of 10 971 operators (16.5%) and 892 of 1662 facilities (53.7%) performing an average of 1 or more ULM PCI annually. After adjustment, major adverse clinical events occurred more frequently with ULM PCI compared with all other PCI (odds ratio, 1.46; 95% CI, 1.39-1.53). Compared with clinical trial populations, patients in the CathPCI Registry were older with more comorbid conditions, and adverse events were more frequent. Conclusions and Relevance Use of ULM PCI has increased over time, but overall use remains low. These findings suggest that ULM PCI occurs infrequently in the United States and in an older and more comorbid population than that seen in clinical trials.
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Affiliation(s)
- Javier A Valle
- Rocky Mountain Veterans Affairs Medical Center, Aurora, Colorado.,University of Colorado School of Medicine, Aurora
| | - Hector Tamez
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - J Dawn Abbott
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Issam D Moussa
- Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Stephen W Waldo
- Rocky Mountain Veterans Affairs Medical Center, Aurora, Colorado.,University of Colorado School of Medicine, Aurora
| | | | | | - Robert W Yeh
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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15
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Association between Hospital volume of cardiopulmonary resuscitation for in-hospital cardiac arrest and survival to Hospital discharge. Resuscitation 2020; 148:25-31. [PMID: 31945429 DOI: 10.1016/j.resuscitation.2019.12.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/17/2019] [Accepted: 12/31/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Prior studies have shown that hospital case volume is not associated with survival in patients with out-of-hospital cardiac arrest (OHCA). However, how case volume impact on survival for in-hospital cardiac arrest (IHCA) is unknown. METHODS We queried the National Inpatient Sample (NIS) in the U.S. 2005-2011 to identify cases in which in-hospital CPR was performed for IHCA. Restricted cubic spine was used to evaluate the association between hospital annual CPR volume and survival to hospital discharge. RESULTS Across more than 1000 hospitals in NIS, we identified 125,082 cases (mean age 67, 45% female) of IHCA for which CPR was performed over the study period. Median [Q1, Q3] case volume was 60 [34, 99]. Compared to those in the 1 st quartile of case volume, hospitals in the 4th quartile tends to have younger patients (mean = 66 vs 68 yrs), higher comorbidities (median Elixhauser score = 4 vs 3), and in low income areas (37 vs 30%). Overall, 23% of the patients survived to hospital discharge. There was a non-linear association between CPR volume and survival: a non-significant trend towards better survival was observed with increasing annual CPR volume that reached a plateau at 51-55 cases per year, after which survival began to drop and became significantly lower after 75 cases per year (p for non-linearity<0.001). Compared to those in first quartile of case volume, hospitals in 4th quartile had higher length of stay (median = 8 vs 10 days, respectively) and higher rate of non-routine home discharge (64% vs 67%) among those who survived. CONCLUSION Unlike OHCA, low CPR volume is an indicator of good performing hospitals and increasing CPR case volume does not translate to improve survival for IHCA.
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16
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Fanaroff AC, Zakroysky P, Wojdyla D, Kaltenbach LA, Sherwood MW, Roe MT, Wang TY, Peterson ED, Gurm HS, Cohen MG, Messenger JC, Rao SV. Relationship Between Operator Volume and Long-Term Outcomes After Percutaneous Coronary Intervention. Circulation 2019; 139:458-472. [PMID: 30586696 DOI: 10.1161/circulationaha.117.033325] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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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Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology (A.C.F., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Pearl Zakroysky
- Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Daniel Wojdyla
- Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Matthew W Sherwood
- Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC.,Division of Cardiology, Inova Heart and Vascular Institute, Falls Church, VA (M.W.S.)
| | - Matthew T Roe
- Division of Cardiology (A.C.F., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Tracy Y Wang
- Division of Cardiology (A.C.F., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Eric D Peterson
- Division of Cardiology (A.C.F., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
| | - Hitinder S Gurm
- Division of Cardiology, University of Michigan, Ann Arbor (H.S.G.)
| | | | | | - Sunil V Rao
- Division of Cardiology (A.C.F., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., P.Z., D.W., L.A.K., M.W.S., M.T.R., T.Y.W., E.D.P., S.V.R.), Duke University, Durham, NC
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Kim JG, Choi JC, Kim DJ, Bae HJ, Lee SJ, Park JM, Park TH, Cho YJ, Lee KB, Lee J, Kim DE, Cha JK, Kim JT, Lee BC. Effect of the Number of Neurointerventionalists on Off-Hour Endovascular Therapy for Acute Ischemic Stroke Within 12 Hours of Symptom Onset. J Am Heart Assoc 2019; 8:e011933. [PMID: 31625423 PMCID: PMC6898823 DOI: 10.1161/jaha.119.011933] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Off‐hour presentation can affect treatment delay and clinical outcomes in endovascular therapy (EVT) for acute ischemic stroke. We aimed to examine the treatment delays and clinical outcomes of EVT between on‐ and off‐hour admission and to evaluate the effect of hospital procedure volume and the number of neurointerventionalists on off‐hour EVT. Methods and Results From a multicenter registry, we identified patients who were treated with EVT within 12 hours of symptom. Annual hospital procedure volume was divided as low (<30), medium (30–60), and high (>60). The effect of the number of neurointerventionalists and annual hospital procedure volume on clinical outcome was estimated by the generalized estimation equation. Of the 31 133 stroke patients, 1564 patients met the eligibility criteria (mean age: 69±12 years; median baseline National Institutes of Health stroke scale score, 15 [interquartile range, 10–19]). Of 1564 patients, 893 (57.1%) arrived during off‐hour. The off‐hour patients had greater median door‐to‐puncture time (110 versus 95 minutes; P<0.001) compared with on‐hour patients. Despite the treatment delay, the functional outcome at 3 months did not differ between off‐ and on‐hour (odds ratio with 95% CI for 3‐month modified Rankin Scale 0–2, 0.99 [0.78–1.25]; P=0.90). The presence of three neurointerventionalists was significantly associated with favorable outcomes at 3 months during on‐ and off‐hour (2.07 [1.53–2.81]; P<0.001). The association was not observed for annual hospital procedural volume and the functional outcomes. Conclusions The number of neurointerventionalists was more crucial to effective around‐the‐clock EVT for acute stroke patients than hospital procedural volume.
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Affiliation(s)
- Joong-Goo Kim
- Department of Neurology Jeju National University Hospital Jeju Korea
| | - Jay Chol Choi
- Department of Neurology Jeju National University Hospital Jeju Korea.,School of Medicine Jeju National University Jeju Korea
| | - Duk Ju Kim
- School of Medicine Jeju National University Jeju Korea
| | - Hee-Joon Bae
- Department of Neurology Seoul National University Bundang Hospital Seoul National University College of Medicine Seongnam Korea
| | - Soo-Joo Lee
- Department of Neurology Eulji University Hospital Daejeon Korea
| | - Jong-Moo Park
- Department of Neurology Nowon Eulji Medical Center Eulji University Seoul Korea
| | - Tai Hwan Park
- Department of Neurology Seoul Medical Center Seoul Korea
| | - Yong-Jin Cho
- Department of Neurology Ilsan Paik Hospital Inje University Goyang Korea
| | - Kyung Bok Lee
- Department of Neurology Soonchunhyang University College of Medicine Seoul Korea
| | - Jun Lee
- Department of Neurology Yeungnam University Hospital Daegu Korea
| | - Dong-Eog Kim
- Department of Neurology Dongguk University Ilsan Hospital Goyang Korea
| | - Jae-Kwan Cha
- Department of Neurology Dong-A University College of Medicine Busan Korea
| | - Joon-Tae Kim
- Department of Neurology Chonnam National University Hospital Gwangju Korea
| | - Byung-Chul Lee
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Korea
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18
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Vemulapalli S, Carroll JD, Mack MJ, Li Z, Dai D, Kosinski AS, Kumbhani DJ, Ruiz CE, Thourani VH, Hanzel G, Gleason TG, Herrmann HC, Brindis RG, Bavaria JE. Procedural Volume and Outcomes for Transcatheter Aortic-Valve Replacement. N Engl J Med 2019; 380:2541-2550. [PMID: 30946551 DOI: 10.1056/nejmsa1901109] [Citation(s) in RCA: 249] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND During the introduction of transcatheter aortic-valve replacement (TAVR) in the United States, requirements regarding procedural volume were mandated by the Centers for Medicare and Medicaid Services as a condition of reimbursement. A better understanding of the relationship between hospital volume of TAVR procedures and patient outcomes could inform policy decisions. METHODS We analyzed data from the Transcatheter Valve Therapy Registry regarding procedural volumes and outcomes from 2015 through 2017. The primary analyses examined the association between hospital procedural volume as a continuous variable and risk-adjusted mortality at 30 days after transfemoral TAVR. Secondary analysis included risk-adjusted mortality according to quartile of hospital procedural volume. A sensitivity analysis was performed after exclusion of the first 12 months of transfemoral TAVR procedures at each hospital. RESULTS Of 113,662 TAVR procedures performed at 555 hospitals by 2960 operators, 96,256 (84.7%) involved a transfemoral approach. There was a significant inverse association between annualized volume of transfemoral TAVR procedures and mortality. Adjusted 30-day mortality was higher and more variable at hospitals in the lowest-volume quartile (3.19%; 95% confidence interval [CI], 2.78 to 3.67) than at hospitals in the highest-volume quartile (2.66%; 95% CI, 2.48 to 2.85) (odds ratio, 1.21; P = 0.02). The difference in adjusted mortality between a mean annualized volume of 27 procedures in the lowest-volume quartile and 143 procedures in the highest-volume quartile was a relative reduction of 19.45% (95% CI, 8.63 to 30.26). After the exclusion of the first 12 months of TAVR procedures at each hospital, 30-day mortality remained higher in the lowest-volume quartile than in the highest-volume quartile (3.10% vs. 2.61%; odds ratio, 1.19; 95% CI, 1.01 to 1.40). CONCLUSIONS An inverse volume-mortality association was observed for transfemoral TAVR procedures from 2015 through 2017. Mortality at 30 days was higher and more variable at hospitals with a low procedural volume than at hospitals with a high procedural volume. (Funded by the American College of Cardiology Foundation National Cardiovascular Data Registry and the Society of Thoracic Surgeons.).
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Affiliation(s)
- Sreekanth Vemulapalli
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
| | - John D Carroll
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
| | - Michael J Mack
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
| | - Zhuokai Li
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
| | - David Dai
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
| | - Andrzej S Kosinski
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
| | - Dharam J Kumbhani
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
| | - Carlos E Ruiz
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
| | - Vinod H Thourani
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
| | - George Hanzel
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
| | - Thomas G Gleason
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
| | - Howard C Herrmann
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
| | - Ralph G Brindis
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
| | - Joseph E Bavaria
- From the Division of Cardiology, Duke University Medical Center (S.V.), the Duke Clinical Research Institute (S.V., Z.L., D.D., A.S.K.), and the Department of Biostatistics and Bioinformatics, Duke University (A.S.K.) - all in Durham, NC; the Division of Cardiology, Department of Medicine, University of Colorado, Aurora (J.D.C.); Baylor Scott and White Heart Hospital, Plano (M.J.M.), and the Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (D.J.K.) - both in Texas; the Division of Cardiology, Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (C.E.R.); the Division of Cardiothoracic Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC (V.H.T.); the Division of Cardiology, William Beaumont Hospital, Royal Oak, MI (G.H.); the University of Pittsburgh School of Medicine, Pittsburgh (T.G.G.); the Divisions of Cardiology (H.C.H.) and Cardiothoracic Surgery (J.E.B.), University of Pennsylvania, Philadelphia; and the Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco (R.G.B.)
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Temporal trends in the practice of the transradial approach for percutaneous coronary intervention in a large tertiary center. Coron Artery Dis 2019; 31:40-48. [PMID: 31205054 DOI: 10.1097/mca.0000000000000764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The transradial approach (TRA) has increasingly been adopted for the use of percutaneous coronary interventions (PCI), with reported clinical benefits. Little is known regarding the change in outcomes over time. PATIENTS AND METHODS From our large single-center PCI registry, we have analyzed 15 429 patients in two periods - 2008-2012 (period 1) and 2013-2017 (period 2). We examined the proportions of use of TRA, the influence on in-hospital outcomes, and adjusted long-term effects. RESULTS The rate of TRA rose from 15.9% in period 1 to 69.1% in period 2, including in specific situations such as acute coronary syndrome, chronic total occlusion, bifurcation, calcified lesions, and unprotected left main PCI. In-hospital rates of bleeding were lower for TRA versus transfemoral artery (1.8 vs. 5.1%, overall, P < 0.001), as were rates of additional bleeding events in the following 12 months (1.3 vs. 2.4%, P < 0.001). Following multivariate analysis, use of TRA was associated with a lower 30-day and 4-year rate of the composite outcomes of death, myocardial infarction, target vessel revascularization, or coronary artery bypass surgery [at 4 years, hazard ratio (HR) = 0.86; 95% confidence interval (CI): 0.77-0.96; P = 0.007, during period 1 and HR = 0.62; 95% CI 0.55-0.7; P < 0.0001 during period 2]. Interaction analysis showed a stronger effect at the latter period (HR = 0.69, 95% CI: 0.59-0.81, P < 0.001). CONCLUSION Over a decade of follow-up, TRA has gained acceptance for different PCI scenarios, including complex patients - a course which is associated with consistent short and long-term clinical benefits.
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Improving Quality and Outcomes in TAVR: Turning Up the Volume? J Am Coll Cardiol 2019; 73:441-443. [PMID: 30704576 DOI: 10.1016/j.jacc.2018.09.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/11/2018] [Indexed: 11/21/2022]
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The Impact of Formal Training and Certification on the Relationship Between Volume and Outcomes in Percutaneous Coronary Interventions. Crit Pathw Cardiol 2018; 17:155-160. [PMID: 30044257 DOI: 10.1097/hpc.0000000000000153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Little data are available on the impact of formal training and certification on the relationship between volumes and outcome in percutaneous coronary interventions (PCIs).The objective of this report is to study the relationship between PCI volume and outcome for a formally trained interventional cardiologist who is certified by the American Board on Internal Medicine - Interventional Cardiology subspecialty board. METHODS The operator witnessed 3 different PCI volumes/yr over a 15-year practice period (2000-2014): <50 PCI/yr (years 2000-2006; n = 179), 50-100 PCI/yr (years 2007-2010; n = 256), and >100 PCI/yr (years 2011-2014; n = 427). Angiographic and procedural success rates were compared between the 3 volume groups, as well as in-hospital cardiovascular events (death, recurrent myocardial infarction, repeat PCI, stroke, or coronary artery bypass surgery). RESULTS The in-hospital mortality rate throughout the study period was 0.8% and was not statistically significant among the 3 volume groups. There was also no significant difference among the 3 groups with respect to recurrent myocardial infarction or repeat PCI. There was a slightly higher rate of same-stay elective coronary artery bypass grafting in the early low-volume period compared with the other 2 groups (2.2% vs. 0.8% vs. 0.2%; P = 0.04). The overall angiographic and procedural success rates were 97.3% and 96.5%, and they were not significantly different among the 3 groups. CONCLUSIONS Our study shows that the angiographic and procedural success rates of PCI, as well as the in-hospital mortality, do not seem to be dependent on the annual volume for formally trained and certified interventional cardiologists.
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Relation of Bleeding Events to Mortality in Patients With ST-Segment Elevation Myocardial Infarction Treated by Percutaneous Coronary Intervention (a DANAMI-3 Substudy). Am J Cardiol 2018; 121:781-788. [PMID: 29402421 DOI: 10.1016/j.amjcard.2017.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/15/2017] [Accepted: 12/29/2017] [Indexed: 01/14/2023]
Abstract
Bleeding events in relation to treatment of ST-segment elevation myocardial infarction (STEMI) have previously been associated with mortality. In this study, we investigated the incidence and prognosis of, and variables associated with serious bleedings within 30 days after primary percutaneous coronary intervention in patients from The Third Danish Study of Optimal Acute Treatment of Patients with ST-Segment Elevation Myocardial Infarction (DANAMI-3) (n = 2,217). Hospital charts were read within 30 days postadmission to assess bleeding events using thrombolysis in myocardial infarction (TIMI) and Bleeding Academic Research Consortium criteria. TIMI minor/major bleeding (TMMB) occurred in 59 patients (2.7%). Variables associated with TMMB were female gender (hazard ratio [HR] 3.9, 95% confidence interval [CI] 2.2 to 6.7, p <0.0001), symptom-to-catheterization time >3 hours (HR 1.9, 95% CI 1.1 to 3.3, p = 0.02), use of glycoprotein IIb/IIIa inhibitor (HR 2.1, 95% CI 1.2 to 3.7, p = 0.01), and increasing S-creatinine (HR 1.1, 95% CI 1.0 to 1.2, p = 0.001). Undergoing 2 in-hospital procedures were not associated with increased risk of TMMB. TMMB was strongly associated with 30-day mortality in multivariable analysis (HR 4.8, 95% CI 2.2 to 10.4, p <0.0001) but not with mortality days 31 to 365. When excluding fatal bleedings from the analysis, a TMMB was no longer associated with 30-day mortality. In conclusion, we found that in a contemporary STEMI-population, the incidence of 30-day TMMB was low. A TMMB was strongly associated with 30-day mortality but not with mortality days 31 to 365. If patients survived a serious bleeding, their short- and long-term prognoses were not affected.
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23
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Hulme W, Sperrin M, Curzen N, Kinnaird T, De Belder MA, Ludman P, Kwok CS, Gale CP, Cockburn J, Kontopantelis E, Mamas MA. Operator volume is not associated with mortality following percutaneous coronary intervention: insights from the British Cardiovascular Intervention Society registry. Eur Heart J 2018; 39:1623-1634. [DOI: 10.1093/eurheartj/ehy125] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 03/02/2018] [Indexed: 12/18/2022] Open
Affiliation(s)
- William Hulme
- Farr Institute, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Matthew Sperrin
- Farr Institute, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Nick Curzen
- Wessex Cardiothoracic Centre, University Hospital Southampton and Faculty of Medicine, University of Southampton, Southampton, UK
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Mark A De Belder
- Department of Cardiology, The James Cook University Hospital, Middlesbrough, UK
| | - Peter Ludman
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele and Academic Department of Cardiology, Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, UK
| | - Chris P Gale
- MRC Bioinformatics Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - James Cockburn
- Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK
| | - Evangelos Kontopantelis
- Farr Institute, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele and Academic Department of Cardiology, Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, UK
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Gargiulo G, Heg D, Ferrari F, Percoco G, Campo G, Tumscitz C, Colombo F, Zuffi A, Castriota F, Cremonesi A, Windecker S, Valgimigli M. Stent and Dual Antiplatelet Therapy Duration Comparisons in the Setting of a Multicenter Randomized Controlled Trial: Can the Operator Experience Affect the Study Results? J Am Heart Assoc 2017; 6:JAHA.117.007150. [PMID: 29275371 PMCID: PMC5779027 DOI: 10.1161/jaha.117.007150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Operator experience influences outcomes after percutaneous coronary intervention, but this association in the controlled setting of a randomized, clinical trial is unclear. Methods and Results We investigated operator‐related outcomes (30‐day and 2‐year efficacy and safety end points) among patients undergoing percutaneous coronary intervention and randomized to different dual antiplatelet therapy durations and stent types. A total of 2003 patients were analyzed, and 7 operator groups were compared. The majority of preprocedural and postprocedural characteristics were imbalanced. The primary end point of the study, the composite of death, myocardial infarction, or cerebrovascular accidents, did not differ among operators at 30 days or 2 years. There were no significant differences also for all other individual and composite end points analyzed at 30 days and 2 years, except for 2‐year stent thrombosis (P=0.048) and bleeding events (P=0.022 for Bleeding Academic Research Consortium type 2, 3, or 5). Adjusted comparisons for the main end points showed slight differences among operators at 30 days, but not at 2 years. There was no interaction of operator with dual antiplatelet therapy duration (P=0.112) or stent type (P=0.300). Results remained entirely consistent when operators were stratified by their experience. Conclusions There was a weak signal of heterogeneity across study operators for the 30‐day, but not the 2‐year, main study outcomes. No clear effect of operator or operator experience was observed for the comparative efficacy and safety profile of the randomized stent types or dual antiplatelet therapy duration regimens. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00611286.
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Affiliation(s)
- Giuseppe Gargiulo
- Department of Cardiology, Bern University Hospital, University of Bern, Switzerland.,Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Dik Heg
- Clinical Trial Unit (CTU) Bern, Department of Clinical Research, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
| | | | | | - Gianluca Campo
- Cardiology Unit, University of Ferrara, Cona (FE), Italy
| | - Carlo Tumscitz
- Cardiology Unit, University of Ferrara, Cona (FE), Italy
| | - Federico Colombo
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Zuffi
- Institut Cardiovasculaire de Caen, Hôpital privé Saint Martin, Caen, France
| | | | | | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Switzerland
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25
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O'Neill D, Nicholas O, Gale CP, Ludman P, de Belder MA, Timmis A, Fox KAA, Simpson IA, Redwood S, Ray SG. Total Center Percutaneous Coronary Intervention Volume and 30-Day Mortality: A Contemporary National Cohort Study of 427 467 Elective, Urgent, and Emergency Cases. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003186. [PMID: 28320707 DOI: 10.1161/circoutcomes.116.003186] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 02/20/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relationship between procedural volume and prognosis after percutaneous coronary intervention (PCI) remains uncertain, with some studies finding in favor of an inverse association and some against. This UK study provides a contemporary reassessment in one of the few countries in the world with a nationally representative PCI registry. METHODS AND RESULTS A nationwide cohort study was performed using the national British Cardiovascular Intervention Society registry. All adult patients undergoing PCI in 93 English and Welsh NHS hospitals between 2007 and 2013 were analyzed using hierarchical modeling with adjustment for patient risk. Of 427 467 procedures (22.0% primary PCI) in 93 hospitals, 30-day mortality was 1.9% (4.8% primary PCI). 87.1% of centers undertook between 200 and 2000 procedures annually. Case mix varied with center volume. In centers with 200 to 399 PCI cases per year, a smaller proportion were PCI for ST-segment-elevation myocardial infarction (8.4%) than in centers with 1500 to 1999 PCI cases per year (24.2%), but proportionally more were for ST-segment-elevation myocardial infarction with cardiogenic shock (8.4% versus 4.3%). For the overall PCI cohort, after risk adjustment, there was no significant evidence of worse, or better, outcomes in lower volume centers from our own study, or in combination with results from other studies. For primary PCI, there was also no evidence for increased or decreased mortality in lower volume centers. CONCLUSIONS After adjustment for differences in case mix and clinical presentation, this study supports the conclusion of no trend for increased mortality in lower volume centers for PCI in the UK healthcare system. CLINICAL TRIAL REGISTRATION https://www.clinicaltrials.gov. Unique identifier: NCT02184949.
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Affiliation(s)
- Darragh O'Neill
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.).
| | - Owen Nicholas
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Chris P Gale
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Peter Ludman
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Mark A de Belder
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Adam Timmis
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Keith A A Fox
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Iain A Simpson
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Simon Redwood
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Simon G Ray
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
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26
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Lu TH, Li ST, Liang FW, Lee JC, Yin WH. When high-volume PCI operators in high-volume hospitals move to lower volume hospitals-Do they still maintain high volume and quality of outcomes? Catheter Cardiovasc Interv 2017; 92:644-650. [PMID: 29086474 DOI: 10.1002/ccd.27403] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 09/23/2017] [Accepted: 10/14/2017] [Indexed: 11/12/2022]
Abstract
OBJECTIVES The aim of this quasi-experimental study was to examine whether high-volume percutaneous coronary intervention (PCI) operators still maintain high volume and quality of outcomes when they moved to lower volume hospitals. BACKGROUND Systematic reviews have indicated that high-volume PCI operators and hospitals have higher quality outcomes. However, little is known on whether high PCI volume and high quality outcomes are mainly due to operator characteristics (i.e., skill and experience) and is portable across organizations or whether it is due to hospital characteristics (i.e., equipment, team, and management system) and is less portable. METHODS We used Taiwan National Health Insurance claims data 2000-2012 to identify 98 high-volume PCI operators, 10 of whom moved from one hospital to another during the study period. We compared the PCI volume, risk-adjusted mortality ratio, and major adverse cardiovascular event (MACE) ratio before and after moving. RESULTS Of the 10 high-volume operators who moved, 6 moved from high- to moderate- or low-volume hospitals, with median annual PCI volumes (interquartile range) of 130 (117-165) in prior hospitals and 54 (46-84) in subsequent hospitals (the hospital the operator moved to), and the remaining 4 moved from high to high-volume hospitals, with median annual PCI volumes (interquartile range) of 151 (133-162) in prior hospitals and 193 (178-239) in subsequent hospitals. No significant differences were observed in the risk-adjusted mortality ratios and MACE ratios between high-volume operators and matched controls before and after moving. CONCLUSIONS High-volume operators cannot maintain high volume when they moved from high to moderate or low-volume hospitals; however, the quality of care is maintained. High PCI volume and high-quality outcomes are less portable and more hospital bound.
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Affiliation(s)
- Tsung-Hsueh Lu
- Department of Public Health, The NCKU Research Center for Health Data and College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sheng-Tun Li
- Department of Industrial and Information Management, National Cheng Kung University, Tainan, Taiwan
| | - Fu-Wen Liang
- Department of Public Health, The NCKU Research Center for Health Data and College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jo-Chi Lee
- Department of Public Health, The NCKU Research Center for Health Data and College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Hsian Yin
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, and Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan
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27
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Tra J, de Blok C, van der Wulp I, de Bruijne MC, Wagner C. Multicentre analysis of current ST-elevation myocardial infarction acute care pathways. Open Heart 2017; 4:e000458. [PMID: 28890792 PMCID: PMC5566983 DOI: 10.1136/openhrt-2016-000458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/23/2016] [Accepted: 12/20/2016] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Rapid reperfusion with percutaneous coronary intervention (PCI) is vital for patients with ST segment elevation myocardial infarction (STEMI). However, the guideline-recommended time targets are regularly exceeded. The goal of this study was to gain insight into how Dutch PCI centres try to achieve these time targets by comparing their care processes with one another and with the European guideline-recommended process. In addition, accelerating factors perceived by care providers were identified. METHODS In this multiple case study, interviews with STEMI care providers were conducted, transcribed and used to create process descriptions per centre. Analyses consisted of within-case and between-case analyses of the processes. Accelerating factors were identified by means of open and axial coding. RESULTS In total, 28 interviews were conducted in six PCI centres. The centres differed from the guideline-recommended process on, for example, additional, unavoidable patient routings and monitoring delays, and from one another on the communication of diagnostic information (eg, transmitting all, only ambiguous or no ECGs) and catheterisation room preparation. These differences indicated diverging choices to maintain a balance between speed and diagnostic accuracy. Factors perceived by care providers as accelerating the process included trust in the tentative diagnosis, and avoiding unnecessary intercaregiver consultations. The combination of processes and accelerating factors were summarised in a model. CONCLUSIONS Numerous differences in processes between PCI centres were identified. Several time-saving strategies were applied by PCI centres, however, in different configurations. To further improve the care for patients with STEMI, best practices can be shared between centres and countries.
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Affiliation(s)
- Joppe Tra
- Department of Occupational and Public Health, EMGO+/VU University Medical Center, Amsterdam, The Netherlands
| | - Carolien de Blok
- Faculty of Economics and Business, Department of Operations, University of Groningen, Groningen, The Netherlands
| | - Ineke van der Wulp
- Department of Occupational and Public Health, EMGO+/VU University Medical Center, Amsterdam, The Netherlands
| | - Martine C de Bruijne
- Department of Occupational and Public Health, EMGO+/VU University Medical Center, Amsterdam, The Netherlands
| | - Cordula Wagner
- Department of Occupational and Public Health, EMGO+/VU University Medical Center, Amsterdam, The Netherlands.,The Netherlands Institute of Health Services Research (NIVEL), Utrecht, The Netherlands
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28
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Hsu RCJ, Salika T, Maw J, Lyratzopoulos G, Gnanapragasam VJ, Armitage JN. Influence of hospital volume on nephrectomy mortality and complications: a systematic review and meta-analysis stratified by surgical type. BMJ Open 2017; 7:e016833. [PMID: 28877947 PMCID: PMC5588977 DOI: 10.1136/bmjopen-2017-016833] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/22/2017] [Accepted: 06/28/2017] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES The provision of complex surgery is increasingly centralised to high-volume (HV) specialist hospitals. Evidence to support nephrectomy centralisation however has been inconsistent. We conducted a systematic review and meta-analysis to determine the association between hospital case volumes and perioperative outcomes in radical nephrectomy, partial nephrectomy and nephrectomy with venous thrombectomy. METHODS Medline, Embase and the Cochrane Library were searched for relevant studies published between 1990 and 2016. Pooled effect estimates for nephrectomy mortality and complications were calculated for each nephrectomy type using the DerSimonian and Laird random-effects model. Sensitivity analyses were performed to examine the effects of heterogeneity on the pooled effect estimates by excluding studies with the heaviest weighting, lowest methodological score and most likely to introduce bias from misclassification of standardised hospital volume. RESULTS Some 226 372 patients from 16 publications were included in our review and meta-analysis. Considerable between-study heterogeneity was noted and only a few reported volume-outcome relationships specifically in partial nephrectomy or nephrectomy with venous thrombectomy.HV hospitals were correlated with a 26% and 52% reduction in mortality for radical nephrectomy (OR 0.74, 95% CI 0.61 to 0.90, p<0.01) and nephrectomy with venous thrombectomy (OR 0.48, 95% CI 0.29 to 0.81, p<0.01), respectively. In addition, radical nephrectomy in HV hospitals was associated with an 18% reduction in complications (OR 0.82, 95% CI 0.73 to 0.92, p<0.01). No significant volume-outcome relationship in mortality (OR 0.84, 95% CI 0.31 to 2.26, p=0.73) or complications (OR 0.85, 95% CI 0.55 to 1.30, p=0.44) was observed for partial nephrectomy. CONCLUSIONS Our findings suggest that patients undergoing radical nephrectomy have improved outcomes when treated by HV hospitals. Evidence of this in partial nephrectomy and nephrectomy with venous thrombectomy is however not yet clear and could be secondary to the low number of studies included and the small patient number in our analyses. Further investigation is warranted to establish the full potential of nephrectomy centralisation particularly as existing evidence is of low quality with significant heterogeneity.
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Affiliation(s)
- Ray C J Hsu
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Theodosia Salika
- Epidemiology of Cancer Healthcare and Outcomes(ECHO) Group, Department of Behavioural Science and Health, University College London, London, UK
| | - Jonathan Maw
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes(ECHO) Group, Department of Behavioural Science and Health, University College London, London, UK
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - Vincent J Gnanapragasam
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James N Armitage
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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29
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Lee KY, Wan Ahmad WA, Low EV, Liau SY, Anchah L, Hamzah S, Liew HB, Mohd Ali RB, Ismail O, Ong TK, Said MA, Dahlui M. Comparison of the treatment practice and hospitalization cost of percutaneous coronary intervention between a teaching hospital and a general hospital in Malaysia: A cross sectional study. PLoS One 2017; 12:e0184410. [PMID: 28873473 PMCID: PMC5584952 DOI: 10.1371/journal.pone.0184410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 08/23/2017] [Indexed: 11/25/2022] Open
Abstract
Introduction The increasing disease burden of coronary artery disease (CAD) calls for sustainable cardiac service. Teaching hospitals and general hospitals in Malaysia are main providers of percutaneous coronary intervention (PCI), a common treatment for CAD. Few studies have analyzed the contemporary data on local cardiac facilities. Service expansion and budget allocation require cost evidence from various providers. We aim to compare the patient characteristics, procedural outcomes, and cost profile between a teaching hospital (TH) and a general hospital (GH). Methods This cross-sectional study was conducted from the healthcare providers’ perspective from January 1st to June 30th 2014. TH is a university teaching hospital in the capital city, while GH is a state-level general hospital. Both are government-funded cardiac referral centers. Clinical data was extracted from a national cardiac registry. Cost data was collected using mixed method of top-down and bottom-up approaches. Total hospitalization cost per PCI patient was summed up from the costs of ward admission and cardiac catheterization laboratory utilization. Clinical characteristics were compared with chi-square and independent t-test, while hospitalization length and cost were analyzed using Mann-Whitney test. Results The mean hospitalization cost was RM 12,117 (USD 3,366) at GH and RM 16,289 (USD 4,525) at TH. The higher cost at TH can be attributed to worse patients’ comorbidities and cardiac status. In contrast, GH recorded a lower mean length of stay as more patients had same-day discharge, resulting in 29% reduction in mean cost of admission compared to TH. For both hospitals, PCI consumables accounted for the biggest proportion of total cost. Conclusions The high PCI consumables cost highlighted the importance of cost-effective purchasing mechanism. Findings on the heterogeneity of the patients, treatment practice and hospitalization cost between TH and GH are vital for formulation of cost-saving strategies to ensure sustainable and equitable cardiac service in Malaysia.
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Affiliation(s)
- Kun Yun Lee
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- * E-mail:
| | - Wan Azman Wan Ahmad
- Division of Cardiology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ee Vien Low
- Pharmaceutical Services Division, Ministry of Health, Selangor, Malaysia
| | - Siow Yen Liau
- Department of Pharmacy, Queen Elizabeth 2 Hospital, Sabah, Malaysia
- Clinical Research Centre, Queen Elizabeth 2 Hospital, Sabah, Malaysia
| | - Lawrence Anchah
- Department of Pharmacy, Sarawak General Hospital Heart Centre, Sarawak, Malaysia
| | - Syuhada Hamzah
- Administrative Office, Penang General Hospital, Penang, Malaysia
| | - Houng-Bang Liew
- Clinical Research Centre, Queen Elizabeth 2 Hospital, Sabah, Malaysia
- Division of Cardiology, Queen Elizabeth 2 Hospital, Sabah, Malaysia
| | - Rosli B. Mohd Ali
- Department of Cardiology, National Heart Institute, Kuala Lumpur, Malaysia
| | - Omar Ismail
- Division of Cardiology, Penang General Hospital, Penang, Malaysia
| | - Tiong Kiam Ong
- Department of Cardiology, Sarawak General Hospital Heart Centre, Sarawak, Malaysia
| | - Mas Ayu Said
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Maznah Dahlui
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Carroll JD, Vemulapalli S, Dai D, Matsouaka R, Blackstone E, Edwards F, Masoudi FA, Mack M, Peterson ED, Holmes D, Rumsfeld JS, Tuzcu EM, Grover F. Procedural Experience for Transcatheter Aortic Valve Replacement and Relation to Outcomes. J Am Coll Cardiol 2017; 70:29-41. [DOI: 10.1016/j.jacc.2017.04.056] [Citation(s) in RCA: 199] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/17/2017] [Accepted: 04/19/2017] [Indexed: 12/01/2022]
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Doll JA, Dai D, Roe MT, Messenger JC, Sherwood MW, Prasad A, Mahmud E, Rumsfeld JS, Wang TY, Peterson ED, Rao SV. Assessment of Operator Variability in Risk-Standardized Mortality Following Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2017; 10:672-682. [DOI: 10.1016/j.jcin.2016.12.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 12/07/2016] [Accepted: 12/16/2016] [Indexed: 11/17/2022]
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Hulme W, Sperrin M, Rushton H, Ludman PF, De Belder M, Curzen N, Kinnaird T, Kwok CS, Buchan I, Nolan J, Mamas MA. Is There a Relationship of Operator and Center Volume With Access Site-Related Outcomes? An Analysis From the British Cardiovascular Intervention Society. Circ Cardiovasc Interv 2016; 9:e003333. [PMID: 27162213 DOI: 10.1161/circinterventions.115.003333] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 03/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Transradial access is associated with reduced access site-related bleeding complications and mortality post percutaneous coronary intervention. The objective of this study is to examine the relationship between access site practice and clinical outcomes and how this may be influenced by operator and center experience/expertise. METHODS AND RESULTS The influence of operator and center experience/expertise was studied on 30-day mortality, in-hospital major adverse cardiovascular events (a composite of in-hospital mortality and in-hospital myocardial infarction and target vessel revascularization) and in-hospital major bleeding based on access site adopted (radial versus femoral). Operator/center experience/expertise were defined by both total volume and transradial access proportion. A total of 164 395 procedures between 2012 and 2013 in the National Health Service in England and Wales were analyzed. After case-mix adjustment, transradial access was associated with an average odds reduction of 39% for 30-day mortality compared with transfemoral access (odds ratio, 0.61; 95% confidence interval, 0.55-0.68; P<0.001). The magnitude of this risk reduction was modified by increases in total procedural volume and radial proportion at the operator level (odds ratio reduction of 11% per 100 extra procedures, 95% confidence interval, 3%-19%; odds ratio reduction of 6% per 10%-point increase in radial proportion, 95% confidence interval, 1%-11%) with no significant impact of operator radial volume, center total volume, center radial volume, and center radial proportion. CONCLUSIONS The lower mortality associated with transradial access adoption relates to both the total procedural volume and the proportion of procedures undertaken radially by operator, with operators undertaking the greatest proportion of their procedures radially having the largest relative reduction in mortality risk.
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Affiliation(s)
- William Hulme
- From the Farr Institute, Institute of Population Health, University of Manchester, Manchester, United Kingdom (W.H., M.S., H.R., I.B., M.A.M.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.D.B.); Department of Cardiology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care and Health Sciences, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.); and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands Trust, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.)
| | - Matthew Sperrin
- From the Farr Institute, Institute of Population Health, University of Manchester, Manchester, United Kingdom (W.H., M.S., H.R., I.B., M.A.M.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.D.B.); Department of Cardiology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care and Health Sciences, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.); and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands Trust, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.)
| | - Helen Rushton
- From the Farr Institute, Institute of Population Health, University of Manchester, Manchester, United Kingdom (W.H., M.S., H.R., I.B., M.A.M.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.D.B.); Department of Cardiology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care and Health Sciences, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.); and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands Trust, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.)
| | - Peter F Ludman
- From the Farr Institute, Institute of Population Health, University of Manchester, Manchester, United Kingdom (W.H., M.S., H.R., I.B., M.A.M.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.D.B.); Department of Cardiology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care and Health Sciences, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.); and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands Trust, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.)
| | - Mark De Belder
- From the Farr Institute, Institute of Population Health, University of Manchester, Manchester, United Kingdom (W.H., M.S., H.R., I.B., M.A.M.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.D.B.); Department of Cardiology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care and Health Sciences, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.); and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands Trust, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.)
| | - Nick Curzen
- From the Farr Institute, Institute of Population Health, University of Manchester, Manchester, United Kingdom (W.H., M.S., H.R., I.B., M.A.M.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.D.B.); Department of Cardiology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care and Health Sciences, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.); and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands Trust, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.)
| | - Tim Kinnaird
- From the Farr Institute, Institute of Population Health, University of Manchester, Manchester, United Kingdom (W.H., M.S., H.R., I.B., M.A.M.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.D.B.); Department of Cardiology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care and Health Sciences, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.); and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands Trust, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.)
| | - Chun Shing Kwok
- From the Farr Institute, Institute of Population Health, University of Manchester, Manchester, United Kingdom (W.H., M.S., H.R., I.B., M.A.M.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.D.B.); Department of Cardiology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care and Health Sciences, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.); and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands Trust, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.)
| | - Iain Buchan
- From the Farr Institute, Institute of Population Health, University of Manchester, Manchester, United Kingdom (W.H., M.S., H.R., I.B., M.A.M.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.D.B.); Department of Cardiology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care and Health Sciences, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.); and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands Trust, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.)
| | - James Nolan
- From the Farr Institute, Institute of Population Health, University of Manchester, Manchester, United Kingdom (W.H., M.S., H.R., I.B., M.A.M.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.D.B.); Department of Cardiology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care and Health Sciences, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.); and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands Trust, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.)
| | - Mamas A Mamas
- From the Farr Institute, Institute of Population Health, University of Manchester, Manchester, United Kingdom (W.H., M.S., H.R., I.B., M.A.M.); Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom (P.F.L.); Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.D.B.); Department of Cardiology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom (N.C.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care and Health Sciences, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.); and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands Trust, Stoke-on-Trent, United Kingdom (C.S.K., J.N., M.A.M.).
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Abstract
Percutaneous coronary intervention (PCI) is an integral treatment modality for acute coronary syndromes (ACS) as well as chronic stable coronary artery disease (CAD) not responsive to optimal medical therapy. This coupled with studies on the feasibility and safety of performing PCI in centers without on-site surgical backup led to widespread growth of PCI centers. However, this has been accompanied by a recent steep decline in the volume of PCIs at both the operator and hospital level, which raises concerns regarding minimal procedural volumes required to maintain necessary skills and favorable clinical outcomes. The 2011 ACC/AHA/SCAI competency statement required PCI be performed by operators with a minimal procedural volume of >75 PCIs annually at high-volume centers with >400 PCIs per year, a number which was relaxed in the 2013 ACC/AHA/SCAI update to >50 PCIs/operator/year in hospitals with >200 PCIs annually to coincide with reduction in national PCI volume. Recent data suggests that many hospitals do not meet these thresholds. We review data on the importance of volume as a vital quality metric at both an operator and hospital level in determining procedural outcomes following PCI.
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Morche J, Mathes T, Pieper D. Relationship between surgeon volume and outcomes: a systematic review of systematic reviews. Syst Rev 2016; 5:204. [PMID: 27899141 PMCID: PMC5129247 DOI: 10.1186/s13643-016-0376-4] [Citation(s) in RCA: 227] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 11/08/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The surgeon volume-outcome relationship has been discussed for many years and its existence or nonexistence is of importance for various reasons. A lot of empirical work has been published on it. We aimed to summarize systematic reviews in order to present current evidence. METHODS Medline, Embase, Cochrane database of systematic reviews (CDSR), and health technology assessment websites were searched up to October 2015 for systematic reviews on the surgeon volume-outcome relationship. Reviews were critically appraised, and results were extracted and synthesized by type of surgical procedure/condition. RESULTS Thirty-two reviews reporting on 15 surgical procedures/conditions were included. Methodological quality of included systematic reviews assessed with the assessment of multiple systematic reviews (AMSTAR) was generally moderate to high albeit included literature partly neglected considering methodological issues specific to volume-outcome relationship. Most reviews tend to support the presence of a surgeon volume-outcome relationship. This is most clear-cut in colorectal cancer, bariatric surgery, and breast cancer where reviews of high quality show large effects. CONCLUSIONS When taking into account its limitations, this overview can serve as an informational basis for decision makers. Our results seem to support a positive volume-outcome relationship for most procedures/conditions. However, forthcoming reviews should pay more attention to methodology specific to volume-outcome relationship. Due to the lack of information, any numerical recommendations for minimum volume thresholds are not possible. Further research is needed for this issue.
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Affiliation(s)
- Johannes Morche
- Institute of Health Economics and Clinical Epidemiology, The University Hospital of Cologne (AöR), Gleueler Str. 176-178, 50935, Cologne, Germany
| | - Tim Mathes
- Faculty of Health, School of Medicine, Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany.
| | - Dawid Pieper
- Faculty of Health, School of Medicine, Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany
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35
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Kim LK, Looser P, Swaminathan RV, Minutello RM, Wong SC, Girardi L, Feldman DN. Outcomes in patients undergoing coronary artery bypass graft surgery in the United States based on hospital volume, 2007 to 2011. J Thorac Cardiovasc Surg 2016; 151:1686-92. [DOI: 10.1016/j.jtcvs.2016.01.050] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 01/11/2016] [Accepted: 01/26/2016] [Indexed: 11/25/2022]
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Rashid M, Sperrin M, Ludman PF, O'Neill D, Nicholas O, de Belder MA, Mamas MA. Impact of operator volume for percutaneous coronary intervention on clinical outcomes: what do the numbers say?: Table 1. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2016; 2:16-22. [DOI: 10.1093/ehjqcco/qcv030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Indexed: 12/25/2022]
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ST Elevation Myocardial Infarction Mortality Among Patients With Liver Cirrhosis: A Nationwide Analysis Across a Decade. J Clin Gastroenterol 2015; 49:778-83. [PMID: 25319740 DOI: 10.1097/mcg.0000000000000251] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Mortality from ST elevation myocardial infarction (STEMI) is decreasing nationwide, but no report to date examined STEMI mortality among patients with cirrhosis. GOALS Determine mortality rates and investigate possible disparities in cardiovascular interventions for patients with and without cirrhosis admitted with STEMI across a decade using a national database. STUDY We included all urgent/emergent admissions with STEMI to acute care hospitals across the United States in 1999 and 2009. Exclusion criteria were age less than 18 years or prior liver transplantation. Confounders were accounted for using multivariable regression analyses. RESULTS A total of 325,857 and 182,491 patients with STEMI were included in 1999 and 2009, respectively, 741 and 541 of whom had cirrhosis, respectively. In-hospital mortality rate was 31% and 11% for patients with and without cirrhosis in 1999, and 17% and 9% in 2009. The adjusted mortality odds ratio was 2.54 (1.52 to 4.24) in 1999 and 1.45 (0.73 to 2.86) in 2009. Stent placement rate was 11% and 26% for patients with and without cirrhosis in 1999, and increased to 47% and 61% in 2009, respectively. Thrombolytic medication injection rate was 3% and 10% for patients with and without cirrhosis in 1999, and 0% and 2% in 2009, respectively. Coronary artery bypass graft surgery rate was 3% and 9% for patients with and without cirrhosis in 1999, and was 6% and 7% in 2009, respectively. CONCLUSIONS STEMI mortality in patients with cirrhosis is higher compared with patients without cirrhosis. However, this mortality difference declined from 1999 to 2009, likely because of higher coronary artery stent utilization for patients with cirrhosis.
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Rhudy JP, Bakitas MA, Hyrkäs K, Jablonski-Jaudon RA, Pryor ER, Wang HE, Alexandrov AW. Effectiveness of regionalized systems for stroke and myocardial infarction. Brain Behav 2015; 5:e00398. [PMID: 26516616 PMCID: PMC4614047 DOI: 10.1002/brb3.398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/18/2015] [Accepted: 08/16/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI. METHODS Literature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non- or pre-regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking "regionalization" and "myocardial infarction" or citation as a model system by any American Heart Association statement. RESULTS For AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre- or nonregionalized state. The final yield was nine papers from six systems. CONCLUSION Although regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.
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Affiliation(s)
- James P Rhudy
- School of Nursing University of Alabama at Birmingham Alabama
| | - Marie A Bakitas
- School of Nursing University of Alabama at Birmingham Alabama
| | - Kristiina Hyrkäs
- Center for Nursing Research and Quality Outcomes Maine Medical Center Birmingham Alabama
| | | | - Erica R Pryor
- School of Nursing University of Alabama at Birmingham Alabama
| | - Henry E Wang
- Department of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama
| | - Anne W Alexandrov
- College of Nursing University of Tennessee Health Sciences Center Memphis Tennessee
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39
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The effect of hospital factors on mortality rates after abdominal aortic aneurysm repair. J Vasc Surg 2014; 60:1446-51. [DOI: 10.1016/j.jvs.2014.08.111] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 08/12/2014] [Indexed: 11/21/2022]
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40
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Baron SJ, Yeh RW, Cohen DJ. The challenges of success: maintaining access to high-quality percutaneous coronary intervention in the face of declining procedural volumes. Circulation 2014; 130:1343-5. [PMID: 25189216 DOI: 10.1161/circulationaha.114.012640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Suzanne J Baron
- From the Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO (S.J.B., D.J.C.); and Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.Y.)
| | - Robert W Yeh
- From the Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO (S.J.B., D.J.C.); and Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.Y.)
| | - David J Cohen
- From the Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO (S.J.B., D.J.C.); and Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.Y.).
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