Jollis, James G.

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Journal of the American College of Cardiology Vol. 53, No. 7, 2009
© 2009 by the American College of Cardiology Foundation ISSN 0735-1097/09/$36.00
Published by Elsevier Inc. doi:10.1016/j.jacc.2008.10.039EDITORIAL COMMENT
he New York
tate Primary Angioplasty
egistry and Procedural Volume*
ames G. Jollis, MD, FACC
urham, North Carolina
Nam in omnibus fere minus ualent praecepta quam
experimenta. [In almost everything, experience is more valuable
than precept.]
—Marcus Fabius Quintilian,
De Institutione Oratoria (II, 5, 15) (1)
n 80-year-old woman is found by paramedics with crush-
ng chest pain, a systolic blood pressure of 60 mm Hg in the
eft arm and 80 mm Hg in the right arm, and 4 to 6 mm of
T-segment elevation across the precordial leads. The
edics have 2 options: transport to Hospital A, 5 min away,
hich routinely performs diagnostic coronary angiography
nd occasionally performs coronary angioplasty in urgent
ituations, or transport the patient to Hospital B, 30 min
way, which performs more than 600 angioplasties per year.
n concert with local cardiologists, the emergency medical
ystem director has established a pre-specified “destination
lan” directing the medics to transport patients with ST-
egment elevation myocardial infarction (STEMI) to one of
hese hospitals.
See page 574
Since the original observation by Hal Luft in 1978
howing fewer deaths among patients undergoing proce-
ures at greater-volume hospitals, the issue of “volume and
utcome” has vexed the medical profession (2). In 1988, the
merican College of Cardiology first adopted a physician
olume standard of “about 1 case/week” to maintain profi-
iency (3). This seemingly minimal standard unleashed a
restorm of controversy by physicians concerned about
xclusion from angioplasty based upon a guideline lacking
mpirical evidence. In response to the call for supporting
vidence, the standards were rewritten 5 years later after
areful review of volume-outcome relationships in available
Editorials published in the Journal of the American College of Cardiology reflect the
iews of the authors and do not necessarily represent the views of JACC or the
merican College of Cardiology.N
From the Duke University Medical Center, Durham, North Carolina. Dr. Jollis has
eceived grant support from United Healthcare, Genentech, and Sanofi-Aventis.ngioplasty registries and claims data. According to an
nflection point for increasing mortality below 75 cases/year,
he guidelines increased the minimum operator volume
tandard and recommended at least 200 cases/year for
ospitals (4). The reaction of some interventionalists re-
ained forceful, as exemplified by the appearance of buttons
ith a red slash through number 75 at national meetings.
ost recently, with the emerging national mandate to
rovide prompt primary angioplasty to all patients with
TEMI, the benefit of transferring patients to high-volume
egional percutaneous coronary intervention (PCI) centers
ust be weighed against the additional risk of delayed
reatment. The volume-outcome relationship is most appar-
nt among high-risk patients, and STEMI patients have the
ost to gain from experienced PCI teams and the most to
ose from delays (5,6).
In this issue of the Journal, Srinivas et al. (7) provide an
nalysis of the volume-outcome relationship for primary
CI in contemporary data. This study is remarkable for a
umber of reasons. The New York State registry likely
epresents the best available data by which to examine
olume and outcome in the U.S. Unlike national registries,
articipation in the New York State PCI registry is man-
atory and global, so that all operators and hospitals,
ncluding lower-volume institutions, must participate (8).
hus, the New York data offer a greater opportunity to
onsider PCI in widespread practice. Other significant
dvantages of the New York data compared with national
egistries involve data verification. Rather than relying on
elf-reported complications and mortality, the New York
egistry is cross-referenced with state vital status data,
esulting in verified and highly reliable mortality measures.
atient risk factors also are subject to verification by chart
eview by the Department of Health.
The work, in which 7,321 patients undergoing primary
CI are examined, identifies significant associations be-
ween procedural volume and in-hospital mortality accord-
ng to physician and hospital volume. The New York data
lso identify interactions between physician and hospital
olume, with trends for better outcomes for patients treated
y greater-volume physicians at greater-volume institutions.
he finding of an interaction between physician and hos-
ital volume is not uniform, but small “cell size” issues,
articularly in stratifying patients treated by high-volume
hysicians in low-volume hospitals, likely contribute to
eterogeneity in these observations. Thus, 25 years after
uft’s original observation, some of the best data available in
oronary revascularization continue to identify mortality
ifferences according to physician and hospital volume for
rimary angioplasty.
What is to be done with these data? First, the data must
e viewed in the context of an observational study. Patients
reated at lower-volume hospitals and by lower-volume
hysicians were sicker according to a number of measures.
o amount of adjustment in regression models can com-
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581JACC Vol. 53, No. 7, 2009 Jollis
February 17, 2009:580–1 NY State Angioplasty Registry and Volumeletely separate the greater illness severity from worse
utcomes. This finding suggests that some portion of the
elationship may be due to selection bias. Outcomes may
ppear better at high-volume hospitals if the sickest patients
re deemed too unstable to transfer or die in transfer before
eaching their catheterization laboratories.
Similarly, the relationship between physician volume and
ospital volume is highly confounded, and the relative
ontribution of each to better outcomes cannot be com-
letely defined. One of the most significant criticisms of the
pplication of volume-outcome observations to public policy
nvolves the potential exclusion of “quality” low-volume
roviders. Because of small numbers, statistical techniques
re unable to differentiate low-volume providers with above-
verage skills from low-volume providers with above-
verage luck. Because patients “on average” fare better with
reater-volume physicians and hospitals, guidelines and
ublic policy that take into account volume will lead to the
est overall outcomes.
The last important issue raised by the findings of Srinivas
t al. (7) involves the underlying causes of the consistent
nding of lower mortality for patients treated by greater-
olume providers. In addition to differences in illness
everity and selection bias noted previously, the most plau-
ible explanation involves experience. In practical terms, the
ifference between survival and death often involves a PCI
eam that can recognize and manage severe complications.
hen coronary interventions are proceeding well, modern
echniques and devices are capable of restoring coronary
ow in an expedient and successful fashion. The value of
xperience does not become apparent until the interven-
ional team is called upon to manage infrequent but extreme
ituations. Following the patient example mentioned previ-
usly, any number of situations related to inexperience could
ead to a poor outcome: failure to recognize that a guide
atheter has entered a false lumen and is extending an aortic
issection; inadequate resuscitative efforts with weak chest
ompressions and slow intra-aortic balloon pump prepara-
ion and deployment; or “back walling” the femoral artery in
hypotensive patient with diminished femoral pulses lead-
ng to a large retroperitoneal bleed.
Although experience, selection bias, and illness severity
ll contribute to the observed differences in mortality rates,
hese data continue to suggest that primary angioplasty is
est performed on a regular basis by experienced cardiac
K
heams. Returning to the issues of STEMI systems raised by
ur patient, most primary angioplasty facilities can be staffed
nd prepared to treat patients within 30 min. Thus, policies
hould generally direct STEMI patients to greater-volume
acilities that are within 30 min if these facilities are
outinely capable of rapid activation by referring emergency
hysicians and paramedics on a 24 h/day, 7 days/week basis.
o meet the needs of our patients and fulfill the public
olicy mandate of these consistent observations, experienced
hysicians and hospitals should make every effort to provide
rimary PCI on a timely and round-the-clock basis.
eprint requests and correspondence to: Dr. James G. Jollis, Box
254, Duke University Medical Center, Durham, North Carolina
7710. E-mail: james.jollis@duke.edu.
EFERENCES
. Quintilian. Institutio Oratoria: Book 2, Chapter 5. Reinhardt T,
Winterbottom M, editors. Oxford: Oxford University Press, 2006:11.
. Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized?
The empirical relation between surgical volume and mortality. N Engl
J Med 1979;301:1364–9.
. Ryan TJ, Faxon DP, Gunnar RM, et al. Guidelines for percutaneous
transluminal coronary angioplasty: a report of the American College of
Cardiology/American Heart Association Task Force on Assessment of
Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee
on Percutaneous Transluminal Coronary Angioplasty). J Am Coll
Cardiol 1988;12:529–45.
. Ryan TJ, Bauman WB, Kennedy JW, et al. Guidelines for percutaneous
transluminal coronary angioplasty. A report of the American College of
Cardiology/American Heart Association Task Force on Assessment of
Diagnostic and Therapeutic Cardiovascular Procedures (Committee on
Percutaneous Transluminal Coronary Angioplasty). J Am Coll Cardiol
1993;22:2033–54.
. Jollis JG, Peterson ED, Nelson CL, et al. Relationship between
physician and hospital coronary angioplasty volume and outcome in
elderly patients. Circulation 1997;95:2485–91.
. Hannan EL, Wu C, Walford G, et al. Volume-outcome relationships
for percutaneous coronary interventions in the stent era. Circulation
2005;112:1171–9.
. Srinivas VS, Hailpern SM, Koss E, Monrad ES, Alderman MH. Effect
of physician volume on the relationship between hospital volume and
mortality during primary angioplasty. J Am Coll Cardiol 2009;53:
574–9.
. Nallamothu BK, Wang Y, Curtis JP, et al. Contemporary analysis of the
association between hospital volume and in-hospital death in patients
undergoing percutaneous coronary intervention: results from the Na-
tional Cardiovascular Data Registry (abstr). Circulation 2006;114:
II836.ey Words: primary angioplasty y coronary disease y outcome y
ospital volume y physician volume.


The New York State Primary Angioplasty Registry and Procedural Volume⁎⁎Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. 

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The New York State Primary Angioplasty Registry and Procedural Volume⁎⁎Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.

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