"Practice makes perfect" seems logical, but how much practice remains uncertain, and current health care quality guidelines may be set too high. It may be time to reexamine the standard recommending hospitals perform at least 400 angioplasty and
stent procedures per year, according to
a new study in the May 19, 2004 issue of the
Journal of the American College of Cardiology.
"The 400 level might be too high, at least from an evidence point of view," said Harlan M. Krumholz, MD, FACC from the Yale University School of Medicine. "We don't have evidence that you always need to go that high to get the same outcomes. The minimum volume standard is probably a moving target with evolving technology and cumulative operator experience. As a result we might be better served with something other than the volume standard, except for the very lower end of the spectrum. Instead, we should develop more of an outcome-based assessment."
Both the Leapfrog Group (a collection of large health care purchasers) and the American College of Cardiology/American Heart Association guidelines recommend that hospitals perform at least 400 percutaneous coronary interventions (PCI) a year. The procedures include angioplasty and stent placement to reopen coronary arteries.
In order to see whether that standard actually predicted better patient survival, Dr. Krumholz, along with Andrew J. Epstein, MPP and others at Yale and the University of Pennsylvania, analyzed federal administrative billing records on 362,748 patients who underwent PCI between 1998 and 2000. They compared death rates while patients were still in the hospital to the procedure volume for the hospital.
After adjusting the data to account for differences in disease severity, age, and other patient characteristics, the researchers found that although death rates were higher in low-volume hospitals (less than 200 procedures per year), there was not a statistically significant difference between the death rates in medium-volume hospitals (200 to 399 procedures per year) and those in high or very-high volume hospitals (400 procedures or more per year). The study did not evaluate the success of the procedure or the occurrence of non-fatal complications.
Dr. Krumholz said the results of this study indicate that while patients may have reason to question the performance of low-volume hospitals that average less than one procedure a day, there may be legitimate reasons for choosing a hospital that doesn't quite meet the standard of 400 procedures per year.
"We're saying that if a hospital is in the medium-volume category, we don't have any evidence that you are losing anything by going there. And people may have a lot of reasons for going there; they may want to stick with their doctor, they want to stay closer to home and so on," Dr. Krumholz said.