Het volume van chirurgische ingrepen en de impact ervan op ... - KCE

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166 Volume Outcome KCE reports 113 There was no information on severity score. 283 McGrath et al. described how lowervolume hospitals were more likely to perform PCI on patients admitted with AMI, but, on the other hand, there were more patients with a Charlson score >1 in high-volume hospitals. Age was similar across volume categories. 304 The external experts who commented on our study were not surprised by the higher percentage of patients with AMI in low-volume centres. They argued that low-volume centres perform more emergency PCIs. A patient who presents himself with an acute myocardial infarction at a low-volume hospital can not wait to be transferred to a high-volume hospital, whereas patients who are scheduled for an elective PCI have a choice. However, many studies use clinical data to adjust for case mix. Hannan et al. found that “patients in higher-volume hospitals were significantly older and were significantly more likely to have had left main disease, more vessels diseased, a type C lesion, previous stroke, aortoiliac disease, congestive heart failure, previous PCIs and open heart operations, and stent during the index procedure.” Patients in lower-volume hospitals were significantly more likely to have had chronic obstructive pulmonary disease and diabetes. Nevertheless, Hannan emphasised that these statistically significant differences were more likely to be attributable to large sample sizes rather than to clinical significance. 284 Overall, the studies based on clinical databases use a variety of clinical characteristics: 284, 285, 297-299 • Cardiac risk factors: smoking, hypertension, hypercholesterolemia, diabetes, mellitus, family history of coronary artery disease; • Medical history of: angina, congestive heart failure, chronic obstructive pulmonary disease, heart surgery, gastro-intestinal bleeding, extra-cardiac vascular disease, atrial fibrillation, renal failure requiring dialysis, stroke, myocardial infarction, CABG, PCI; • Clinical presentation at time of PCI: left ventricular ejection fraction, creatinine level, myocardial infarction within 24 h, rescue PCI, unstable angina, cardiogenic shock, cardiac arrest, anemia (haemoglobin
KCE Reports 113 Volume Outcome 167 Key points on volume outcome association for Percutaneous Coronary Intervention (PCI) • In the Minimal Clinical Data 2004, we identified a total of 21 028 hospital stays during which PCI was performed in one of 29 B2 or B3 centres. Due to the lack of reliable data on the use of drug eluting stents (DES) during these stays, the type of stent (i.e. DES, bare metal stent or balloon angioplasty) could not be taken into account in the analyses • The 29 B2/B3 centres had an average volume of 725 PCIs per year (median 620). Eight out of 29 centres (27%) applied to the international cut off of 400 PCIs per year. The average PCI volume per operator is 93 per year, performed by 215 physicians. • Overall in-hospital mortality after PCI was 1.81% in Belgian B2/B3 hospitals, but is much higher among patients who are admitted with a myocardial infarction i.e. 5.11%. Regression models were fitted to assess the association between hospital or interventionist volume on this outcome. The following factors were taken into account in all analyses: age, sex, Charlson score (co morbidity) and principal diagnosis. • The literature review could only conclude on an inverse relation between volume and mortality for primary PCI, which is synonym for immediate PCI (performed on patients with an acute myocardial infarction, within a limited number of hours after the onset of symptoms). • Belgian data show that observed hospital volume is statistically significantly associated with in-hospital mortality which is 2.8% in low volume centres (< 431 PCI) versus 1.6 and 1.7% in medium and high volume centres. However, this association is entirely explained by the differences in case mix between centres, as no effect remains after risk adjustment. Low volume hospitals had a higher percentage of patients with Charlson score ≥ 3, with AMI as principal diagnosis or with a higher severity index. A subset analysis on primary PCI patients was not possible in Belgian data. • The association between operator volume and outcome was not analysed in Belgian data. • Three complications described in the literature were also studied: emergency CABG (1.07%), AMI (11.6%). However, AMI is not a reliable indicator since huge coding differences exist between the centres. • Some procedures are not identifiable in the MCD and can therefore not be taken into account in the case-mix adjustment. This limitation applies to the type of stent implanted during PCI (i.e. drug eluting stent, bare metal stent or balloon angioplasty). • With respect to PCI, the EuroSCORE (the most frequently used risk profile system in cardiology) would be better for risk adjustment than the applied Charlson score (which takes into account only co morbidities and not patient’s cardiac status). These clinical parameters are, however, not encoded in the MCD.
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