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(Circulation. 2001;104:2155.)
© 2001 American Heart Association, Inc.

Editorials

Operator Volume and Clinical Outcomes of Primary Coronary Angioplasty for Patients With Acute Myocardial Infarction

Mark A. Hlatky, MD; R. Adams Dudley, MD, MBA

From the Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco (R.A.D.); and the Departments of Health Research and Policy and Medicine, Stanford University School of Medicine, Stanford (M.A.H.), Calif.

Correspondence to Mark A. Hlatky, MD, Stanford University School of Medicine, HRP Redwood Building, Room 150, Stanford, CA 94305-5405. E-mail hlatky@stanford.edu

Key Words: Editorials • angioplasty • myocardial infarction

An inverse relationship between the annual number of patients treated by a hospital or physician and rates of mortality and complications has been repeatedly documented. These volume-outcome relationships have been explored in particular detail in cardiovascular medicine, including for procedures such as coronary artery bypass graft surgery and coronary angioplasty and conditions such as acute myocardial infarction. There is considerable controversy regarding how these data should be interpreted and, in particular, whether policies should be based on hospital or physician volume. In the present issue of Circulation, Vakili and associates¹ present data on the effect of operator volume on the outcome of primary angioplasty for acute myocardial infarction. To place this study in context, we will first review the data on volume-outcome relationships, then assess why these relationships exist, and finally discuss what policies might be based on these findings.

See p 2171

The Evidence for Volume-Outcome Relationships in Coronary Angioplasty

The relationship of coronary angioplasty volumes to outcome has been examined in many studies. Jollis and coworkers² analyzed claims data from 1987 through 1990 for 217 836 Medicare beneficiaries and found an inverse relationship between mortality and the annual number of angioplasty procedures performed in a hospital. They found the volume-outcome relationship was J-shaped, ie, had a stronger inverse relationship at low angioplasty volumes than at high volumes. This study highlights several methodological issues common to all studies of volume and outcome. First, very large sample sizes are needed to provide sufficient statistical power to document a relationship between mortality and procedure volume. Second, unless a . . . [Full Text of this Article]

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