Skip to main content

Advertisement

Log in

Percutaneous Coronary Intervention: Relationship Between Procedural Volume and Outcomes

  • Interventional Cardiology (S Rao, Section Editor)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Aversano T, Lemmon CC, Liu L, Atlantic CI. Outcomes of PCI at hospitals with or without on-site cardiac surgery. N Engl J Med. 2012;366:1792–802. This trial suggests that there was no major difference in the mortality and major cardiac events in the patients who underwent percutaneous coronary intervention (PCI) in the hospitals with or without on-site cardiac surgery.

    Article  CAS  PubMed  Google Scholar 

  2. Jacobs AK, Normand SL, Massaro JM, et al. Nonemergency PCI at hospitals with or without on-site cardiac surgery. N Engl J Med. 2013;368:1498–508. This study concludes that there was no significant difference in the major cardiac events, death, myocardial infarction, repeat vascularization, and stroke with respect to 30-day and 1-year rates in hospitals with or without onsite cardiac surgery.

    Article  CAS  PubMed  Google Scholar 

  3. Badheka AO, Patel NJ, Grover P, et al. Impact of annual operator and institutional volume on percutaneous coronary intervention outcomes: a 5-year United States experience (2005–2009). Circulation. 2014;130:1392–406. This study concluded that a strong operator and hospital volume relationship exists in today’s world which is backed up by the National Cardiovascular Data Registry (NCDR).

    Article  PubMed  Google Scholar 

  4. Yeh RW, Sidney S, Chandra M, Sorel M, Selby JV, Go AS. Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med. 2010;362:2155–65. This study concludes that the incidence of myocardial infarction decreased significantly after 2000, and the incidence of ST segment elevation myocardial infarction decreased markedly after 1999. Reductions in the short-term case fatality rate may be attributed to decrease in the incidence of STEMI and lower rate of death after non-STEMI.

    Article  CAS  PubMed  Google Scholar 

  5. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131:e29–322.

    Article  PubMed  Google Scholar 

  6. Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356:1503–16. This study concludes that PCI when used as an initial management strategy in patients with stable coronary artery disease does not reduce the risk of death, MI, or other cardiovascular events when added to optimal medical therapy.

    Article  CAS  PubMed  Google Scholar 

  7. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA, ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012. Appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2012;59:857–81.

    Article  PubMed  Google Scholar 

  8. Maroney J, Khan S, Powell W, Klein LW. Current operator volumes of invasive coronary procedures in Medicare patients: implications for future manpower needs in the catheterization laboratory. Catheter Cardiovasc Interv. 2013;81:34–9. This study depicts that there is a high percentage of low-volume operators performing PCI, raising questions regarding volume recommendations for procedural skill maintenance and the future manpower required in the catheterization laboratory.

    Article  PubMed  Google Scholar 

  9. Dehmer GJ, Weaver D, Roe MT, et al. A contemporary view of diagnostic cardiac catheterization and percutaneous coronary intervention in the United States: a report from the CathPCI Registry of the National Cardiovascular Data Registry, 2010 through June 2011. J Am Coll Cardiol. 2012;60:2017–31. The purpose of this study was to provide a contemporary view of the current practice of invasive cardiology in the United States.

    Article  PubMed  Google Scholar 

  10. Gladwell M. Outliers: the story of success. New York, NY: Little Brown and Company; 2011.

    Google Scholar 

  11. Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? New England Journal of Medicine. 1979;301:1364–9. The purpose of this study was to determine whether there is a relation between a hospital’s surgical volume and its surgical mortality.

    Article  CAS  PubMed  Google Scholar 

  12. Wen HC, Tang CH, Lin HC, Tsai CS, Chen CS, Li CY. Association between surgeon and hospital volume in coronary artery bypass graft surgery outcomes: a population-based study. Ann Thorac Surg. 2006;81:835–42. This study concludes that for all the CABG surgeries taking place in Taiwan, the skill and experience of individual surgeons is a more critical factor for patient outcome than either hospital equipment or surgical teams.

    Article  PubMed  Google Scholar 

  13. Sollano JA, Gelijns AC, Moskowitz AJ et al. Volume-outcome relationships in cardiovascular operations: New York State, 1990–1995. J Thorac Cardiovasc Surg 1999;117:419–28; discussion 428–30. This study concludes that no correlation exists between hospital volume and in-hospital deaths in CABG, which may be largely attributed to the quality improvement program in New York state.

  14. Wang L. The volume-outcome relationship: busier hospitals are indeed better, but why? J Natl Cancer Inst. 2003;95:700–2. This study reveals that outcomes of the patients in the higher volume hospital is better than the hospitals with lower volume.

    Article  PubMed  Google Scholar 

  15. Jollis JG, Peterson ED, DeLong ER, et al. The relation between the volume of coronary angioplasty procedures at hospitals treating Medicare beneficiaries and short-term mortality. N Engl J Med. 1994;331:1625–9. This is a seminal study and one of the first to demonstrate the relationship between coronary balloon angiplasty volume and short-term mortality.

  16. Hannan EL, Wu C, Walford G, et al. Volume-outcome relationships for percutaneous coronary interventions in the stent era. Circulation. 2005;112:1171–9. The relation between the volume of coronary stenting at hospitals treating Medicare beneficiaries and short-term mortality.

    Article  PubMed  Google Scholar 

  17. Post PN, Kuijpers M, Ebels T, Zijlstra F. The relation between volume and outcome of coronary interventions: a systematic review and meta-analysis. Eur Heart J. 2010;31:1985–92. This meta-analysis proves that patients undergoing CABG or PCI in a higher volume hospital exhibit lower in-hospital mortality than those treated at low volume hospitals.

    Article  PubMed  Google Scholar 

  18. Ryan TJ, Klocke FJ, Reynolds WA. Clinical competence in percutaneous transluminal coronary angioplasty. A statement for physicians from the ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology. J Am Coll Cardiol. 1990;15:1469–74.

    Article  CAS  PubMed  Google Scholar 

  19. Riley RF, Don CW, Powell W, Maynard C, Dean LS. Trends in coronary revascularization in the United States from 2001 to 2009: recent declines in percutaneous coronary intervention volumes. Circ Cardiovasc Qual Outcomes. 2011;4:193–7. This study confirms that PCI volume has begun to decrease. Although rates of CABG have waned for several decades, all forms of coronary revascularization have been declining.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Harold JG, Bass TA, Bashore TM, et al. ACCF/AHA/SCAI 2013 update of the clinical competence statement on coronary artery interventional procedures: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training (writing committee to revise the 2007 clinical competence statement on cardiac interventional procedures). Circulation. 2013;128:436–72. This report provided specific recommendations for operator and institutional procedural volumes and provided specific guidelines to promote continuous quality improvement.

    Article  PubMed  Google Scholar 

  21. Jollis JG, Peterson ED, Nelson CL, et al. Relationship between physician and hospital coronary angioplasty volume and outcome in elderly patients. Circulation. 1997;95:2485–91. This study suggests that adherence to minimum volume standards by physicians and hospitals leads to better outcomes for elderly patients undergoing coronary angioplasty.

    Article  CAS  PubMed  Google Scholar 

  22. McGrath PD, Wennberg DE, Dickens Jr JD, et al. Relation between operator and hospital volume and outcomes following percutaneous coronary interventions in the era of the coronary stent. JAMA. 2000;284:3139–44. This study describes that Medicare patients who are treated with high-volume physicians and at high-volume centers experience better outcomes following PCIs.

    Article  CAS  PubMed  Google Scholar 

  23. Hannan EL, Racz M, Ryan TJ, et al. Coronary angioplasty volume-outcome relationships for hospitals and cardiologists. JAMA. 1997;277:892–8. This study concludes that both hospital PTCA volume and cardiologist PTCA volume are significantly inversely related to in-hospital mortality rate and same-stay CABG surgery rate for patients undergoing PTCA.

    Article  CAS  PubMed  Google Scholar 

  24. Burton KR, Slack R, Oldroyd KG, et al. Hospital volume of throughput and periprocedural and medium-term adverse events after percutaneous coronary intervention: retrospective cohort study of all 17,417 procedures undertaken in Scotland, 1997–2003. Heart. 2006;92:1667–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Carey JS, Danielsen B, Gold JP, Rossiter SJ. Procedure rates and outcomes of coronary revascularization procedures in California and New York. J Thorac Cardiovasc Surg. 2005;129:1276–82.

    Article  PubMed  Google Scholar 

  26. Ritchie JL, Phillips KA, Luft HS. Coronary angioplasty. Statewide experience in California. Circulation. 1993;88:2735–43. This study elucidates the mortality and need for CABG surgery in the statewide California PTCA experience is higher than that generally reported in the literature. In patients with an admitting diagnosis of AMI, the overall mortality was higher, as was the need for CABG and the associated CABG mortality. Rates of CABG surgery and the combination of CABG and/or mortality, adjusted only for the presence or absence of AMI, were increased at the low-volume institutions.

    Article  CAS  PubMed  Google Scholar 

  27. Kansagra SM, Curtis LH, Anstrom KJ, Schulman KA. Trends in operator and hospital procedure volume and outcomes for percutaneous transluminal coronary angioplasty, 1996 to 2001. Am J Cardiol. 2007;99:339–43. This study concludes that PCI outcomes were best for patients receiving care from high-volume hospital/operator pairs.

    Article  PubMed  Google Scholar 

  28. Minges K, Wang Y, Dodson J et al. Physician annual volume and in-hospital mortality following percutaneous coronary intervention. AHA, 2011.

  29. Strom JB, Wimmer NJ, Wasfy JH, Kennedy K, Yeh RW. Association between operator procedure volume and patient outcomes in percutaneous coronary intervention: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2014;7:560–6. This study indicates that mortality and major adverse cardiac events increase as operator volume decreases in PCI.

    Article  PubMed  Google Scholar 

  30. Jolly SS, Cairns J, Yusuf S, et al. Procedural volume and outcomes with radial or femoral access for coronary angiography and intervention. J Am Coll Cardiol. 2014;63:954–63. This study describes procedural volume and expertise are important, particularly for radial percutaneous coronary intervention.

    Article  PubMed  Google Scholar 

  31. Kimmel SE, Berlin JA, Strom BL, Laskey WK. Development and validation of simplified predictive index for major complications in contemporary percutaneous transluminal coronary angioplasty practice. The Registry Committee of the Society for Cardiac Angiography and Interventions. J Am Coll Cardiol. 1995;26:931–8. This study provided a predictive index to stratify patients into risk groups before angioplasty for risk assessment, resource allocation, and risk adjustment.

    Article  CAS  PubMed  Google Scholar 

  32. Ho V. Evolution of the volume-outcome relation for hospitals performing coronary angioplasty. Circulation. 2000;101:1806–11. This study explains that overtime, the disparity in the outcome between low- and high-volume hospitals has narrowed, and outcomes have improved significantly for all hospitals and hospitals performing more surgical procedures tend to yield better outcomes.

    Article  CAS  PubMed  Google Scholar 

  33. Madan M, Nikhil J, Hellkamp AS, et al. Effect of operator and institutional volume on clinical outcomes after percutaneous coronary interventions performed in Canada and the United States: a brief report from the Enhanced Suppression of the Platelet glycoprotein IIb/IIIa Receptor with Integrilin Therapy (ESPRIT) study. Can J Cardiol. 2009;25:e269–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Epstein AJ, Rathore SS, Volpp KG, Krumholz HM. Hospital percutaneous coronary intervention volume and patient mortality, 1998 to 2000: does the evidence support current procedure volume minimums? J Am Coll Cardiol. 2004;43:1755–62. This study found out that there was no evidence of higher in-hospital mortality in patients undergoing PCI at medium-volume hospitals compared with patients treated at hospitals with annual PCI volumes greater than 400, suggesting guidelines may merit reevaluation.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Lin HC, Lee HC, Chu CH. The volume-outcome relationship of percutaneous coronary intervention: can current procedure volume minimums be applied to a developing country? Am Heart J. 2008;155:547–52.

    Article  PubMed  Google Scholar 

  36. Tonino PA, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009;360:213–24.

    Article  CAS  PubMed  Google Scholar 

  37. Panaich SS, Badheka AO, Arora S et al. Variability in utilization of drug eluting stents in United States: Insights from nationwide inpatient sample. Catheter Cardiovasc Interv 2015. In press. This study concludes that there is significance between-hospital variations in DES utilization and a higher annual hospital volume is associated with higher utilization rate of DES.

  38. Oh SW, Lee HJ, Chin HJ, Hwang JI. Adherence to clinical practice guidelines and outcomes in diabetic patients. Int J Qual Health Care. 2011;23:413–9.

    Article  PubMed  Google Scholar 

  39. Vikman S, Airaksinen KE, Tierala I, et al. Improved adherence to practice guidelines yields better outcome in high-risk patients with acute coronary syndrome without ST elevation: findings from nationwide FINACS studies. J Intern Med. 2004;256:316–23.

    Article  CAS  PubMed  Google Scholar 

  40. Zahn R, Gottwik M, Hochadel M, et al. Volume-outcome relation for contemporary percutaneous coronary interventions (PCI) in daily clinical practice: is it limited to high-risk patients? Results from the Registry of Percutaneous Coronary Interventions of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK). Heart. 2008;94:329–35. In this study conducted during the contemporary PCI era, the volume-outcome relationship was only apparent in high-risk subgroups, such as myocardial infarction patients.

    Article  CAS  PubMed  Google Scholar 

  41. Srinivas VS, Hailpern SM, Koss E, Monrad ES, Alderman MH. Effect of physician volume on the relationship between hospital volume and mortality during primary angioplasty. J Am Coll Cardiol. 2009;53:574–9.

    Article  CAS  PubMed  Google Scholar 

  42. Kontos MC, Wang Y, Chaudhry SI, et al. Lower hospital volume is associated with higher in-hospital mortality in patients undergoing primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction: A report from the NCDR. Circ Cardiovasc Qual Outcomes. 2013;6:659–67. This report suggests that higher annual hospital volume of primary PCI continues to be associated with lower mortality compared to the hospitals which perform less than 36 PCIs per year.

    Article  PubMed  Google Scholar 

  43. Kumbhani DJ, Cannon CP, Fonarow GC, et al. Association of hospital primary angioplasty volume in ST-segment elevation myocardial infarction with quality and outcomes. JAMA. 2009;302:2207–13. This study describes that higher volume primary angioplasty centers were associated with shorter door-to-balloon times and more use of evidence based treatment than low volume centers, but there was no difference in adjusted in-hospital mortality or length of hospital stay in patients with STEMI.

    Article  CAS  PubMed  Google Scholar 

  44. Sorajja P, Gersh BJ, Cox DA, et al. Impact of multivessel disease on reperfusion success and clinical outcomes in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. Eur Heart J. 2007;28:1709–16.

    Article  PubMed  Google Scholar 

  45. Group TL. Leapfrog evidence-based hospital referral fact sheet, 2004.

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Mauricio G. Cohen.

Ethics declarations

Conflict of Interest

Apurva O. Badheka, Sidakpal S. Panaich, Shilpkumar Arora, Nilay Patel, Nileshkumar J. Patel, Chirag Savani, Abhishek Deshmukh, and Mauricio G. Cohen declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Interventional Cardiology

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Badheka, A.O., Panaich, S.S., Arora, S. et al. Percutaneous Coronary Intervention: Relationship Between Procedural Volume and Outcomes. Curr Cardiol Rep 18, 39 (2016). https://doi.org/10.1007/s11886-016-0709-x

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11886-016-0709-x

Keywords

Navigation