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Paul D. McGrath, MD, MSc; David E. Wennberg, MD, MPH; John D. Dickens, Jr, MD; Andrea E. Siewers, MPH; F. Lee Lucas, PhD; David J. Malenka, MD; Mirle A. Kellett, Jr, MD; Thomas J. Ryan, Jr, MD

JAMA. 2000;284:3139-3144.

Context  Studies have found an association between physician and institution procedure volume for percutaneous coronary interventions (PCIs) and patient outcomes, but whether implementation of coronary stents has allowed low-volume physicians and centers to achieve outcomes similar to their high-volume counterparts is unknown.

Objective  To assess the relationship between physician and hospital PCI volumes and patient outcomes following PCIs, given the availability of coronary stents.

Design, Setting, and Participants  Analysis of data from Medicare National Claims History files for 167 208 patients aged 65 to 99 years who had PCIs performed by 6534 physicians at 1003 hospitals during 1997. Of these procedures, 57.7% involved coronary stents.

Main Outcome Measures  Rates of coronary artery bypass graft (CABG) surgery and 30-day mortality occurring during the index episode of care, stratified by physician and hospital PCI volume.

Results  Overall unadjusted rates of CABG during the index hospitalization and 30-day mortality were 1.87% and 3.30%, respectively. After adjustment for case mix, patients treated by low-volume (<30 Medicare procedures) physicians had an increased risk of CABG vs patients treated by high-volume (>60 Medicare procedures) physicians (2.25% vs 1.55%; P<.001), but there was no difference in 30-day mortality rates (3.25% vs 3.39%; P = .27). Patients treated at low-volume (<80 Medicare procedures) centers had an increased risk of 30-day mortality vs patients treated at high-volume (>160 Medicare procedures) centers (4.29% vs 3.15%; P<.001), but there was no difference in the risk of CABG (1.83% vs 1.83%; P = .96). In patients who received coronary stents, the CABG rate was 1.20% vs 2.78% for patients not receiving stents, and the 30-day mortality rate was 2.83% vs 3.94%. Among patients who received stents, those treated at low-volume centers had an increased risk of 30-day mortality vs those treated at high-volume centers, whereas those treated by low-volume physicians had an increased risk of CABG vs those treated by high-volume physicians.

Conclusion  In the era of coronary stents, Medicare patients treated by high-volume physicians and at high-volume centers experience better outcomes following PCIs.

Author Affiliations: Center for Outcomes Research and Evaluation (Drs McGrath, Wennberg, Dickens, and Lucas and Ms Siewers) and Division of Cardiology, Department of Medicine, Maine Medical Center, Portland (Drs McGrath, Kellett, and Ryan); Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH (Drs Wennberg and Malenka); and Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Dr Malenka).

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