Angioplasty Outcomes May Vary Little Between Hospitals
TUESDAY, Nov. 24 -- Do hospitals that conduct the most angioplasties necessarily produce the best results for patients? Maybe not.
Prior research had suggested that "practice makes perfect" when it comes to artery-opening procedures, but a new study involving over 30,000 patients finds low- and high-volume hospitals performing more or less equally.
The study included patients with what are called primary angioplasties, cared for at 166 hospitals across the United States between 2001 and 2007.
The researchers found no significant difference in outcome between medical centers that did high volumes of such procedures and those that didn't do all that many.
"The message here is that volume alone is not a sufficient target marker for outcome," said study senior author Dr. Deepak Bhatt, chief of cardiology at the VA Boston Healthcare System and associate professor of medicine at Harvard Medical School. His team reported the findings in the Nov. 25 issue of the Journal of the American Medical Association.
Studies done several years ago did find better results at high-volume hospitals, "but I think things have changed," Bhatt said. "Devices and techniques, and overall results have improved."
Hospitals were classified in three groups: low-volume, with fewer than 36 primary angioplasties a year; middle-volume, between 36 and 70 procedures; and high-volume, with 70 or more procedures a year.
The in-hospital death rate was 3 percent for high-volume hospitals, 3.2 percent for medium-volume hospitals and 3.9 percent for low-volume hospitals, a difference that is not statistically significant, the report said.
The length of hospital stays was virtually the same for all hospitals: 4.6 days for low-volume, 4.5 days for medium-volume, 4.7 days for high-volume. But there was a difference in the interval between arrival at the hospital and beginning of angioplasty: 98 minutes for low-volume hospitals, 90 minutes for medium-volume and 88 minutes for high-volume. And high-volume hospitals were more likely to fulfill the guideline recommending start of an angioplasty within 90 minutes of arrival at a hospital.
Overall, the new findings are "really good news for patients in general, because it means that whatever hospital you go to, the result is likely to be good," said Dr. Issam D. Moussa, associate professor of medicine and director of the endovascular service at Weill Medical College of Cornell University, New York City, and a spokesman for the Society for Cardiovascular Angiography and Interventions.
The study results also confirm current guidelines about emergency treatment for heart attacks, Moussa said. "When they pick you up, they should take you to the nearest hospital," he said. "This study doesn't change that."
But he also said the findings of the study were not unshakable because of the relatively small number of people treated in low-volume hospitals.
"Low-volume hospitals [in the study] included only 3,000 patients," Moussa said. "Because of that low number, the results cannot be conclusive."
The difference between in-hospital death rates found in the study might have been statistically significant had the numbers been higher, he said. And the study also excluded about 120 hospitals because they reported too few primary angioplasties, Moussa said.
The study also looked only at in-hospital deaths, Bhatt noted. "If we looked at longer-term outcomes, differences might emerge," he said.
Still, the study casts some doubt on the notion that in cardiology, practice makes perfect, Bhatt noted. "Within the range we studied and the kinds of hospitals we studied, the difference was not there," he said.
In a related study published in the same issue of the journal, Norwegian researchers say that giving out-of-hospital cardiac arrest patients intravenous epinephrine therapy does not boost long-term survival.
A team from Oslo University compared outcomes for over 850 patients experiencing out-of-hospital cardiac arrest. Half received standard IV epinephrine as part of advanced cardiac life support, while the other half did not. The team found that about 10 percent of patients survived to hospital discharge, whether or not they had received the IV treatment.
Emergency treatments for heart attacks are described by the U.S. National Heart, Lung and Blood Institute.
Posted: November 2009
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