Author + information
- Received November 4, 2016
- Revision received December 7, 2016
- Accepted December 16, 2016
- Published online April 3, 2017.
- Jacob A. Doll, MDa,b,∗ (, )
- Dadi Dai, PhDc,
- Matthew T. Roe, MD, MHSc,d,
- John C. Messenger, MDe,
- Matthew W. Sherwood, MD, MHSd,
- Abhiram Prasad, MDf,
- Ehtisham Mahmud, MDg,
- John S. Rumsfeld, MD, PhDh,
- Tracy Y. Wang, MD, MHS, MScc,d,
- Eric D. Peterson, MD, MPHc,d and
- Sunil V. Rao, MDc,d
- aVA Puget Sound Health Care System, Seattle, Washington
- bDivision of Cardiology, University of Washington, Seattle, Washington
- cDuke Clinical Research Institute, Durham, North Carolina
- dDivision of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- eDivision of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
- fDepartment of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
- gDivision of Cardiovascular Medicine, University of California, San Diego Sulpizio Cardiovascular Center, La Jolla, California
- hDenver VA Medical Center, Denver, Colorado
- ↵∗Address for correspondence:
Dr. Jacob A. Doll, VA Puget Sound Health Care System, 1660 S. Columbian Way, S111-CARDIO, Seattle, Washington 98108.
Objectives This study sought to determine variability and stability in risk-standardized mortality rates (RSMR) of percutaneous coronary intervention (PCI) operators meeting minimum case volume standards and identify differences in case mix and practice patterns that may account for RSMR variability.
Background RSMR has been suggested as a metric to evaluate the performance of PCI operators; however, variability of operator-level RSMR and the stability of this metric over time among the same operator are unknown.
Methods The authors calculated mean RSMRs for PCI operators with average annual volume of ≥50 cases in the National Cardiovascular Data Registry CathPCI Registry. Funnel plots were used to account for operator case volume. Demographic, clinical, and treatment variables of patients treated by operators with outlying high or low RSMRs (identified by RMSR greater than or less than 2 σ above or below the mean [analogous to 2 SD], respectively) were compared with nonoutlier operators. RMSR stability was assessed by calculating average annual operator RMSR during the study period and by determining if operators were consistently classified into RMSR categories in each year.
Results Between October 1, 2009, and September 30, 2014, a total of 2,352,174 PCIs were performed at 1,373 hospitals by 3,760 operators. Of these, 242 operators (6.5%) had RSMR >2 σ above the mean and 156 operators (4.1%) had RSMR >2 σ below the mean. Both high and low RSMR outlier operators treated patients with lower expected mortality risk, compared with nonoutlier operators. There was significant instability in annual operator RMSR during the study period.
Conclusions There is significant variability in risk-standardized PCI mortality among U.S. operators meeting minimum volume standards that is not explained by case mix or procedure characteristics. Operator RMSR was unstable from year to year, thus limiting its utility as a sole performance measure for PCI quality.
- coronary artery disease
- percutaneous coronary intervention
- quality measure
- risk standardized mortality rate
This research was supported by the American College of Cardiology Foundation’s National Cardiovascular Data Registry. The views expressed in this manuscript represent those of the authors and do not necessarily represent the official views of the National Cardiovascular Data Registry (NCDR) or its associated professional societies identified at www.ncdr.com. CathPCI Registry is an initiative of the American College of Cardiology with partnering support from The Society for Cardiovascular Angiography and Interventions. Dr. Doll has received a research grant from Gilead. Dr. Roe has received research grants from Eli Lilly, AstraZeneca, Daiichi-Sankyo, Ferring Pharmaceuticals, Janssen Pharmaceuticals, KAI Pharmaceuticals, the Familial Hypercholesterolemia Foundation, and Sanofi; and consulting payments or honoraria from Actelion, Myokardia, Novartis, Daiichi-Sankyo, Quest Diagnostics, AstraZeneca, Eli Lilly, Merck, Janssen, Elsevier Publishers, Amgen, Bristol-Myers Squibb, Boehringer Ingelheim, Pri-Med, and Regeneron. Dr. Sherwood has received research support from AstraZeneca and Gilead; and consulting fees from Boehringer Ingelheim. Dr. Mahmud serves on the advisory board and speakers bureau of Medtronic; consulting and educational programs of Abbott Vascular; and Clinical Events Committee of St. Jude. Dr. Rumsfeld was the Chief Science Officer of the NCDR at the time of this analysis. Dr. Wang has received research grant support from Pfizer, Eli Lilly, Daiichi-Sankyo, AstraZeneca, Bristol-Myers Squibb, Boston Scientific, Gilead, GlaxoSmithKline, and Regeneron; and consulting services from AstraZeneca, Eli Lilly, Merck, Pfizer, and Premier. Dr. Peterson has received institutional grant support from American College of Cardiology, American Heart Association, Eli Lilly, and Janssen; and consulting fees (including CME) from Merck & Co., Boehringer Ingelheim, Genentech, Janssen, AstraZeneca, Bayer AG, and Sanofi. Dr. Rao has received research funding from Bellerophon; and consulting fees from Medtronic, AstraZeneca, and Boehringer Ingelheim. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 4, 2016.
- Revision received December 7, 2016.
- Accepted December 16, 2016.