Hospital Mortality From PCI Is Unrelated to Procedural Volume

Fran Lowry

September 03, 2009

September 3, 2009 (Barcelona, Spain) — Hospital mortality after emergency or elective PCI is unrelated to procedural volume, according to a review of all in-patient PCI procedures done in Germany in 2007. The result puts an end to the widely held notion that centers that do more procedures have better mortality outcomes, said Dr Albrecht Vogt (Burgfeld-Krankenhaus, Kassel, Germany) at the European Society of Cardiology 2009 Congress.

"I've worked as a cardiologist in different large hospitals, and I'm now working in an intermediate hospital. Why should I do interventions less well when working in the intermediate hospital than when working in the large hospital? So I don't believe that bad outcome is a matter of hospital volume. It may be a matter of personal and operator experience, but this is not correlated with hospital volume," Vogt told heartwire .

Most cardiologists in Germany who begin their career in interventional cardiology do so in large teaching or community hospitals. Later, they may move to smaller hospitals, "so why should they perform their job worse than before?" Vogt asked.

He and his colleagues analyzed the complete nationwide reporting of all inpatient PCI procedures and determined that the overall hospital mortality rate for the 236 849 PCIs that were done in Germany's 474 hospitals in 2007 was 2.2%. The majority of these deaths--55%--occurred within 24 hours of transmural MI.

Deaths were determined by the discharge mode from administrative data, and not from physician reports, which are often unreliable, Vogt stressed.

After adjustment for known risk factors for hospital mortality after PCI, including age, gender, acute coronary syndrome with and without ST elevation, shock, diabetes, renal or cardiac failure, and PCI of the left main artery, no mortality differences could be found, either for elective or emergency PCI, regardless of the procedure volume.

Mortality Rates According to Procedure Volume

Procedures/year, n Mortality (%)
5135 2.10
34 741 2.61
62 755 2.16
134 218 2.13

Similar Results in Sweden

Dr Stefan James (Uppsala University Hospital, Uppsala, Sweden), who moderated the session, told heartwire that he thought the German study was good because it used a nationwide registry and included all PCI patients in Germany. "He had a large number of centers, and that is a strength."

However, the fact that the study did not look for other factors that contribute to bad outcomes was a negative, James said.

"The mortality outcome measure might be a bit too general, because there is so much else that is important for mortality. It's not only the procedure itself; it's the hospital quality, it's the medications given, it's the care, so there are a lot of factors that influence mortality. Another weakness was that he wasn't able to present operator volume and compensate for that. That would be another important piece of data to adjust for."

That being said, the same situation exists in Sweden, he said.

"We have very similar results in Sweden. We have a very large data set, and we can't find any differences in any type of measurement--mortality, reinfarction rates, restenosis rates, [target lesion revascularization] TLR rates, bleeding complications, neurologic complications, and hospital stay--between low- and high-volume centers."

This reassuring message about similar mortality outcomes in low- and high-volume centers does not apply in the US, where there are many very small-volume centers, James said. "I still think it is reasonable to have a lower limit. In Sweden, we have set that at around 400 cases per year. But if you go lower than that, we are suspicious. So I still think the current recommendations by the American Heart Association and the American College of Cardiology are okay. We have a different situation in Europe. Our low-volume centers still do reasonable numbers of procedures per year."

Vogt said the issue has become politicized in Germany, where cardiologists from large hospitals are agitating to have all PCI procedures done in high-volume centers. They are a vocal group and are attempting to persuade politicians that this is the way to go.

"They want to close the smaller hospitals, and the politicians like to hear that since they believe they can cut costs by reducing the number of hospitals. I don't think that's true, but they hope to do so. It's a dangerous trend, this collaboration of university cardiologists with politicians, and it's a trend in the wrong direction," said Vogt. He added: "Most German cardiologists don't like to hear about these results."


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