JACC: Experience matters for treating primary PCI patients

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During primary percutaneous coronary intervention (PCI), physician experience significantly modifiesthe hospital volume-outcome relationship, according to a registry published in the Feb. 17 issue of the Journal of the American College of Cardiology.

V.S. Srinivas, MBBS, department of medicine, division of cardiology at Montefiore Medical Center in Bronx, N.Y., and colleagues sought to examine the combined effect of hospital and physicianvolume of primary PCI onin-hospital mortality.Using the N.Y. State PCI registry, the researchers examined yearly hospitalvolume, physician volume and risk-adjusted mortality in 7,321patients undergoing primary PCI for acute MI.Risk-adjusted mortality rates for high-volume hospitals (>50cases/year) and high-volume physicians (>10 cases/year) werecompared with their respective low-volume counterparts.

The authors found that primary PCI by high-volume hospitals and high-volumephysicians was associated withlower odds of mortality. Furthermore, there was a significantinteraction between hospital and physician volume on adjustedmortality.

Although unadjusted mortality was lowerwhen primary PCI was performed by high-volume physicians inhigh-volume hospitals compared with low-volume physicians inlow-volume hospitals (3.2 vs. 6.7 percent), the risk-adjustedmortality rate was not statistically significant (3.8 vs. 8.4 percent), according to the researchers.

In low-volume hospitals, Srinivas and colleagues found that the average risk-adjustedmortality rate for low-volume physicians was 8.4 percent versus 4.8 percentfor high-volume physicians.However, in high-volume hospitals, the risk-adjusted mortalityrate for high-volume physicians was 3.8 percent, compared with 6.5 percent for low-volumephysicians.

According to the researchers, physician volume was "a powerful effect modifier of hospitalvolume on outcome." They said that these outcomes could be explained asa disproportionate case mix of high-risk patients; care-relateddifferences in low-volume hospitals; or operator inexperience.The investigators performed risk adjustment to account for differences in casemix and stratified analyses to equalize the effect of care-relateddifferences. "Despite these measures, low physician volume wasan independent predictor, leaving physician inexperience asthe most plausible explanation for this effect," Srinivas and colleagues said.

Based on their findings, “policymakersneed to consider physician experience when developing strategiesto improve access to primary PCI,” the authors stated.