Feature: Bhatt questions PCI volume as surrogate for hospital quality

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In previous research, investigators have found a direct correlation between hospital primary angioplasty volume and mortality rates in STEMI patients, resulting in a volume criteria for provider settings. However, Deepak L. Bhatt, MD, told Cardiovascular Business News that based on the findings of a recent JAMA study, the volume surrogate should be reconsidered as basis for hospital quality.

To explore these findings further, researchers recently compared primary angioplasty volumes with patient outcomes in STEMI patients. In a Nov. 25 study in the Journal of the American Medical Association, Dharam J. Kumbhani, MD, of the Cleveland Clinic, and colleagues concluded that mortality from small-, medium-, and large-volume PCI hospitals performing angioplasties did not differ considerably.

Bhatt, co-author of the study and chief of cardiology at the VA Boston Healthcare System and director of the integrated interventional cardiovascular program at Brigham and Women’s Hospital in Boston, said that volume often is used as a surrogate for outcomes at PCI hospitals.

Additionally, the researchers went beyond studying rates of mortality and also focused on the relationship between primary angioplasty procedural volumes and other markers of quality of care, such as door-to-balloon times (D2B), patient length of stay and use of evidence-based therapies in STEMI patients.

Since mortality rates and length of stay did not show striking disparities, basing hospital quality on volume should be done with caveats. “Volume in and of itself should not be used as a surrogate measure to evaluate performance at PCI hospitals,” Bhatt advised.

The study, a large sample size of 29,513 STEMI patients, found no evidence that hospital volume was related to mortality. These numbers were consistent in 166 facilities, according to study findings.

“As common sense would suggest, certainly there is a level below where volume does matter, but in the contemporary era, that threshold may vary,” Bhatt noted. “The best measure of outcome is outcome.”

He added that while findings confirmed no correlation between hospital volume and mortality, there was “a correlation with quality of care measures.”

According to Bhatt, all participating facilities in the study strove to meet guidelines put forth by the American Heart Association (AHA) and the American College of Cardiology (ACC) regarding evidence-based practices.

These guidelines, Bhatt asserted, were put in place to improve care. These guiding principles, which advise facilities to have D2B times of 90 minutes or less are “important for a variety of reasons.” But at the top of this list is the notion that these guidelines fuel “standardized care and optimal processes of care” in PCI facilities, he said.

“Over time,” Bhatt emphasized, “studies have shown that compliance with guidelines has improved the healthcare system.” As facilities have become more compliant with these guidelines mortality rates and patient outcomes have begun to improve.

One major change in keeping with the guidelines has been the fostering of D2B times. In the study, high-volume hospitals fared better than small- and medium-volume hospitals in regards to AHA/ACC standards of D2B times of 90-minutes or less.

However, Bhatt added that “over time, door to balloon times have improved since five years ago even in the hospitals we categorized as small and medium.” He noted that data have shown “markedly improved quality measures and D2B times” compared to a decade ago.

“Participation in the AHA “ Get with the Guidelines” quality improvement initiative can help equalize the gap between low and high volume hospitals,” stated Bhatt.

In addition, faster D2B times, he said, have already gone a long way in reducing patient length of stays.

The average length of stay in all facilities was three days. While this is low, a radial artery access approach during coronary intervention could lower it even further, Bhatt said. This technique could also lead to fewer vascular complications.

Bhatt and colleagues offered that better adherence to guidelines at high-volume and low-volume centers “could enable standardization of healthcare delivery across hospitals.”