Practice makes perfect with angioplasty
Practice makes perfect with angioplasty
Low volume makes your facility a liability target
A new study confirms what the American Heart Association (AHA) in Atlanta, has been saying for years: Cardiologists and institutions that perform a low volume of angioplasties have significantly poorer patient outcomes. The study was presented at the AHA’s 69th Scientific Sessions in New Orleans. To reduce liability risks and increase quality control efforts, hospitals should institute a rigorous peer review of angioplasty, says James Jollis, MD, a cardiologist at Duke University Medical Center in Durham, NC, who headed a research team that studied the medical records of 97,478 Medicare patients.
Jollis and his colleagues examined the results of 6,115 physicians who performed 119,886 angioplasties in 1992 the first year physicians were required to submit an identification number on claims forms. The average number of procedures performed per doctor was 39, which is well under the minimum of 75 as recommended by American Heart Association and the American College of Cardiology (ACC) in Bethesda, MD.
"Our study showed that physicians who perform fewer than the recommended number of angioplasties per year have a higher percentage of patients who go on to have bypass surgery or die," says Jollis, whose research was funded by the Office of Health Care Policy and Research in Rockville, MD, as part of a grant to the Ischemic Heart Disease Patient Outcomes Research Team.
The study showed that 6.8% of patients whose physicians performed fewer than 25 angioplasties per year required subsequent bypass surgery or died in the hospital. For physicians who did 25 to 50 procedures annually, the percentage of patients with adverse outcomes dropped to 5.6%. As the physicians’ experiences rose to more than 50 procedures per year, only 4.7% of their patients developed complications or died. Physician performance continued to improve up to 150 procedures per year, but beyond that number, there was little effect on patient outcomes.
The results held true even after adjusting for age, gender, race, disease severity, and complicating co-morbidities such as diabetes, Jollis says.
"The numbers may seem small, but if these patients had been treated by more experienced doctors and had similar results, approximately 2,000 of them would have avoided bypass surgery or death. "While the overall risk of complications from angioplasty is small, physician experience makes a significant difference."
Outcomes also linked to institutional volume
Maintaining competency is also important at the institutional level, he adds. The study showed some facilities were performing more than 1,000 angioplasties per year, but others did as few as one. The median number was 27.
The results were strikingly similar to the physician study.
"Patients treated at hospitals that performed less than the recommended 200 procedures annually were more likely to die or require bypass surgery," Jollis explains.
Hospitals that performed fewer than 100 angioplasties per year had a death rate of 3.6% by 30 days after the procedure. In contrast, hospitals that performed above the 200 minimum cases had a death rate of 2.6% after 30 days.
"This study confirms the old maxim that practice makes perfect,’" Jollis says. "Heart patients do best if they are treated by an experienced doctor at an experienced hospital."
Yet Jollis admits volume requirements are controversial because so many physicians don’t qualify under the present guidelines set by the ACC and AHA panel that recommended volume standards.
The figure for individual volume requirements for physicians was set at 50 procedures per year in 1988 and raised to 75 per year in 1993. The institutional standard remained at 200.
"When the ACC/AHA panel put forward their recommendations, they were estimating how many procedures are sufficient to reduce the risk to patients, but no one had ever measured the impact of physician experience on patient outcomes," Jollis explains.
So in this outcome-oriented world, what can facilities do to make sure their performance is up to par?
Create a rigorous mechanism for valid peer review, says Thomas Ryan, MD, primary author of the Guidelines for Percutaneous Transluminal Coronary Angioplasty, a special report issued by the AHA and the ACC.
"There must be an established, ongoing angioplasty review in each institution because it is a therapeutic modality whose efficacy has a recognized association with operator skill and experience," he says.
The review can take many forms and will vary according to such factors as hospital size, number of staff, departments, and volume of procedures, but Ryan lists the basic requirements for a "meaningful review":
"At minimum, there must be the opportunity for physicians, including those who do not perform PTCAs but are knowledgeable about the procedure, to review the overall results of the program on a regular basis," he says.
Ryan suggests you pay special attention to the following:
• general indications;
• the success and failure rates of individual operators;
• the number of procedures performed per operator;
• the operators’ rates of complications, including emergency surgery procedures;
• mortality rates.
"An active data base for quality assessment issues should also be established," Ryan says.
Pay special attention to volume rates, he says.
While Ryan admits that minimums don’t guarantee competence, "the proliferation of small-volume operators should be curtailed by institutional review."
"To this end, we suggest that angioplasty operators who fail to meet these requirements discontinue their performance of the procedure," he says.
Jollis agrees. "At present we have enough physicians performing a sufficient number of angioplasties to handle the volume of patients," he says.
[Editor’s note: For a copy of the AHA’s Medical/Scientific Statement Special Report on PTCA guidelines, contact the AHAoffice of Communications at: 7272 Greenville Ave, Dallas, TX 75231-4596. Telephone: (214) 706-1173.]
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