Accreditation of Hospitals for Percutaneous Coronary Intervention
Accreditation of Hospitals for Percutaneous Coronary Intervention
Background: The risk of major complications of percutaneous coronary revascularization (PCR) is modestly lower in high-volume as opposed to low-volume hospitals, but this is not a consistent finding for all hospitals. There are also limitations comparing risk-adjusted outcomes between hospitals. We sought to ascertain the effect of credentialing hospitals for PCR, either on the basis of procedural volume or outcome, on clinical outcome, cost and accessibility to treatment, in states of varied population density.
Methods: We evaluated Medicare administrative data sets for all PCRs performed in 9 states during 1994-1995. Based upon volume-and risk-adjusted in-hospital mortality during 1994, hospitals were "accredited"using varying volume and outcome thresholds, and the effect of accreditation using these thresholds was ascertained by analysis of 1995 outcomes. Sensitivity analyses were performed to assess the effect of altered assumptions.
Results: During 1994, one hundred and thirty-three hospitals performed 34,879 PCRs in Medicare patients, with an overall mortality of 1.36%. If credentialing were performed based upon 1994 volumes, a sizable clinical benefit could be expected only if large numbers of catheterization laboratories were "closed", e.g., if laboratories with < 200-300 Medicare cases/year (< 400-900 total cases) were "closed", mortality would be expected to decrease to 0.17-1.07% (maximum and minimum effect). Costs could be minimized by closing laboratories with < 100 Medicare cases/year (best case scenario, $512-$905/patient). Such laboratory closures would require transfer to hospitals > 50 miles distant in 6-38% of patients, but as many as 18-94% of patients in low-density states. If credentialing were done on the basis of 1994 adjusted mortality, a somewhat lesser reduction of risk of death (best case scenario,0.93%), but little improvement in cost, could be expected.
Conclusions: If generalizable, these data suggest that to achieve a sizable reduction in procedure-related mortality by hospital-based credentialing, large numbers of catheterization laboratories would need to be closed and patient access to care would be adversely impacted. Cost savings of a very considerable magnitude may be more readily achieved.
The results of many surgical procedures have been clearly documented to be partially dependent upon the hospital's and surgeon's experience with the procedure. Accumulating evidence suggests that this relationship is valid for percutaneous coronary revascularization (PCR), although the difference, in general, between the results of high-and low-volume hospitals and physicians appears to be modest. For instance, in an analysis of the New York State 1991-1994 experience, Hannan and colleagues reported that the risk-adjusted in-hospital mortality for patients undergoing percutaneous transluminal coronary angioplasty (PTCA)in hospitals with annual caseloads less than 600 was significantly higher (0.96%) than those undergoing procedures at higher volume institutions (0.87%). The likelihood of same-stay bypass surgery was similarly correlated with hospital caseload.
In order to promote the provision of optimal health care services to the public, the American College of Cardiology suggests limiting angioplasty services to hospitals that perform more than 200-400 interventions annually and to physicians who perform more than 50-75 interventions annually. This, however, has the disadvantage of barring from practice many providers with seemingly satisfactory outcomes. Outcome-based credentialing has also been proposed, but it has the limitations of lacking universally accepted outcome definitions and risk adjustment modeling standards, as well as a limited capacity to evaluate low-volume providers due to the necessarily wide confidence intervals in estimating their true outcomes. This analysis was undertaken, utilizing widely accessible Medicare administrative data, to study the potential ramifications of credentialing hospitals based upon their interventional caseload or clinical outcome.
Background: The risk of major complications of percutaneous coronary revascularization (PCR) is modestly lower in high-volume as opposed to low-volume hospitals, but this is not a consistent finding for all hospitals. There are also limitations comparing risk-adjusted outcomes between hospitals. We sought to ascertain the effect of credentialing hospitals for PCR, either on the basis of procedural volume or outcome, on clinical outcome, cost and accessibility to treatment, in states of varied population density.
Methods: We evaluated Medicare administrative data sets for all PCRs performed in 9 states during 1994-1995. Based upon volume-and risk-adjusted in-hospital mortality during 1994, hospitals were "accredited"using varying volume and outcome thresholds, and the effect of accreditation using these thresholds was ascertained by analysis of 1995 outcomes. Sensitivity analyses were performed to assess the effect of altered assumptions.
Results: During 1994, one hundred and thirty-three hospitals performed 34,879 PCRs in Medicare patients, with an overall mortality of 1.36%. If credentialing were performed based upon 1994 volumes, a sizable clinical benefit could be expected only if large numbers of catheterization laboratories were "closed", e.g., if laboratories with < 200-300 Medicare cases/year (< 400-900 total cases) were "closed", mortality would be expected to decrease to 0.17-1.07% (maximum and minimum effect). Costs could be minimized by closing laboratories with < 100 Medicare cases/year (best case scenario, $512-$905/patient). Such laboratory closures would require transfer to hospitals > 50 miles distant in 6-38% of patients, but as many as 18-94% of patients in low-density states. If credentialing were done on the basis of 1994 adjusted mortality, a somewhat lesser reduction of risk of death (best case scenario,0.93%), but little improvement in cost, could be expected.
Conclusions: If generalizable, these data suggest that to achieve a sizable reduction in procedure-related mortality by hospital-based credentialing, large numbers of catheterization laboratories would need to be closed and patient access to care would be adversely impacted. Cost savings of a very considerable magnitude may be more readily achieved.
The results of many surgical procedures have been clearly documented to be partially dependent upon the hospital's and surgeon's experience with the procedure. Accumulating evidence suggests that this relationship is valid for percutaneous coronary revascularization (PCR), although the difference, in general, between the results of high-and low-volume hospitals and physicians appears to be modest. For instance, in an analysis of the New York State 1991-1994 experience, Hannan and colleagues reported that the risk-adjusted in-hospital mortality for patients undergoing percutaneous transluminal coronary angioplasty (PTCA)in hospitals with annual caseloads less than 600 was significantly higher (0.96%) than those undergoing procedures at higher volume institutions (0.87%). The likelihood of same-stay bypass surgery was similarly correlated with hospital caseload.
In order to promote the provision of optimal health care services to the public, the American College of Cardiology suggests limiting angioplasty services to hospitals that perform more than 200-400 interventions annually and to physicians who perform more than 50-75 interventions annually. This, however, has the disadvantage of barring from practice many providers with seemingly satisfactory outcomes. Outcome-based credentialing has also been proposed, but it has the limitations of lacking universally accepted outcome definitions and risk adjustment modeling standards, as well as a limited capacity to evaluate low-volume providers due to the necessarily wide confidence intervals in estimating their true outcomes. This analysis was undertaken, utilizing widely accessible Medicare administrative data, to study the potential ramifications of credentialing hospitals based upon their interventional caseload or clinical outcome.
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