Experience gap linked to angio complications

Are report cards the answer?

Make sure your angioplasty operators are adequately experienced to meet the challenge of unexpected complications. Who does your facility’s balloon angioplasty procedures and what sort of quality standards are in place are essential to getting good outcomes.

Fewer procedures per physician translate into more complications, including death, heart attack, and emergency surgery, suggest two recently published studies.1,2 Some favor a new certification process for interventional cardiologists.

The study data tied annual physician case volume to patient outcome and included tens of thousands of patients. Major complication rates were 9.3% for patients treated by doctors who performed fewer than 70 angioplasties a year vs. 2.9% for patients whose doctors did 270. This amounts to a significant, 69% reduction in complications. (See Cost Management in Cardiac Care, March 1997, p. 39.)

In an editorial accompanying the studies, Paul S. Teirstein, MD, director of interventional cardiology at the Scripps Clinic in LaJolla, CA, writes that perhaps there should be a score card for angioplasty doctors so the public can be informed about the relationship between complications and experience.3 "The devil is in the details," however, he points out. Complication rates between high- and low-volume performers are statistically difficult to compare, and methods for correcting differences in risk are imperfect.

Patient volume guidelines issued in 1992 by the American Heart Association in Dallas and the American College of Cardiology in Bethesda, MD, call for physicians to perform a minimum of 75 angioplasties a year to maintain competency.

Coronary angioplasty has become both simpler and more complex, states Tierstein’s editorial. New tricks of the trade include clot-deterrent drugs — glycoprotein inhibitors — and stents and coils to prop open diseased vessels. The number of patients rushed to emergency bypass surgery has declined as a result. Inexperienced doctors can now successfully handle routine angioplasties.

Complicated procedures widen gap

At the same time, however, the advances have made it tempting for those same inexperienced doctors to attempt to treat patients with serious disease not previously treatable, including complicated vessel blockages involving hard-to-handle calcified deposits. "An inexperienced operator is more likely to achieve an excellent result when undertaking a straightforward procedure but is less likely to succeed if [angioplasty] is more complex or if unexpected complications arise," writes Tierstein in the editorial. And technological advances can only widen the experience gap.

Tierstein recommends continual monitoring of the relationship between patient volume and angioplasty outcomes.

References

1. Ellis SG, Weintraub W, Holmes D, et al. Relation of operator volume and experience to procedural outcome of percutaneous coronary revascularization at hospitals with high interventional volumes. Circulation 1997; 95:2,479.

2. Jollis JG, Peterson ED, Nelson CL, et al. Relationship between physician and hospital coronary angioplasty volume and outcome in elderly patients. Circulation 1997; 95:2,485.

3. Teirstein PS. Credentialing for coronary interventions: Practice makes perfect. Circulation 1997; 95:2,467.