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Is Outcome Better for Cardiac Patients in High-Volume Hospitals?

Do patients fare better after myocardial infarction in hospitals that treat more patients with MI? Do patients undergoing percutaneous coronary interventions (PCIs) do better in centers with higher volume? Two studies were designed to address these questions.

Investigators from academic centers and the manufacturer of tissue plasminogen activator conducted a retrospective analysis of outcomes after MI from 1994 to 1999 for 62,299 patients treated with primary angioplasty or thrombolysis at 446 U.S. hospitals. At hospitals with high volumes of angioplasty, mortality was significantly lower for patients treated with angioplasty than for those treated with thrombolysis (3.4 percent vs. 5.4 percent). The same was true for intermediate-volume hospitals (4.5 percent vs. 5.9 percent). In contrast, at hospitals with low volumes of angioplasty, mortality was not significantly different for angioplasty and thrombolysis (6.2 percent vs. 5.9 percent). Adjustment for patient and hospital characteristics failed to alter these findings.

Another group of investigators retrospectively analyzed Medicare claims for 167,208 patients who underwent PCIs (angioplasty, stenting, or atherectomy) in 1997. After adjustment for patient characteristics, 30-day mortality risk was significantly lower among patients treated at high-volume centers than among those treated at low-volume centers (3.2 vs. 4.3 percent).

Comment: Insightful editorialists point out that these results may be limited by bias and confounding, making elusive the precise relation between hospital volume and outcome. Nonetheless, they conclude that "percutaneous coronary interventions... generally should not be conducted in low-volume hospitals unless there are substantial overriding concerns about geographic or socioeconomic access." Given the enormous policy and financial implications, the issue is likely to remain contentious.

— WC Taylor

Published in Journal Watch General Medicine January 23, 2001

Citation(s):

Magid DJ et al. Relation between hospital primary angioplasty volume and mortality for patients with acute MI treated with primary angioplasty vs thrombolytic therapy. JAMA 2000 Dec 27 284 3131-3138.

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McGrath PD et al. Relation between operator and hospital volume and outcomes following percutaneous coronary interventions in the era of the coronary stent. JAMA 2000 Dec 27 284 3139-3144.

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Jollis JG and Romano PS. Volume-outcome relationship in acute myocardial infarction. JAMA 2000 Dec 27 284 3169-3171.

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• Medline abstract (Free)