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(Circulation. 1997;95:2479.)
© 1997 American Heart Association, Inc.
Articles |
Relation of Operator Volume and Experience to Procedural Outcome of Percutaneous Coronary Revascularization at Hospitals With High Interventional Volumes
From the Cleveland Clinic Foundation, Cleveland, Ohio (S.G.E.); Emory University, Atlanta, Ga (W.W., S.B.K.); Mayo Clinic, Rochester, Minn (D.H.); San Francisco Heart Institute, Daly City, Calif (R.S.); and St Vincent Heart Institute, Portland, Ore (P.C.B.).
Correspondence to Stephen G. Ellis, MD, The Cleveland Clinic Foundation, 9500 Euclid Ave, F-25, Cleveland, OH 44195. E-mail elliss{at}cesmtp.ccf.org
Abstract
Background Although an inverse relation between physician
caseload and complications has been conclusively demonstrated for
several surgical procedures, such data are lacking for
percutaneous coronary intervention, and the
ACC/AHA guidelines requiring 
75 cases per year for operator
"competency" are considered by some physicians to be
arbitrary.
Methods and Results From quality-controlled databases at
five high-volume centers, models predictive of death and the composite
outcome of death, Q-wave infarction, or emergency bypass surgery were
developed from 12 985 consecutively treated patients during 1993
through 1994. Models had moderate to high discriminative capacity (area
under ROC curves, 0.65 to 0.85), were well calibrated, and were not
overfitted by standard tests. These models were used for risk
adjustment, and the relations between both yearly caseload and years of
interventional experience and the two adverse outcome measures were
explored for all 38 physicians with 30 cases per year. The average
physician performed a mean±SD of 163±24 cases per year and had been
practicing angioplasty for 8±5 years. Risk-adjusted measures of both
death and the composite adverse outcome were inversely related to the
number of cases each operator performed annually but bore no relation
to total years of experience. Both adverse outcomes were more closely
related to the logarithm of caseload (for death, r=.37,
P=.01; for death, Q-wave infarction, or bypass surgery,
r=.58, P<.001) than to linear caseload.
Conclusions In this analysis, high-volume operators had a lower incidence of major complications than did lower-volume operators, but the difference was not consistent for all operators. If these data are validated, their implications for hospital, physician, and payer policy will require exploration.
Key Words: angioplasty • coronary disease • mortality
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