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Exploring the Relationship Between Volume and Outcomes in Hospital Cardiovascular Care

Langabeer, James R. II PhD; Kim, Junghyun PhD; Helton, Jeffrey PhD

doi: 10.1097/QMH.0000000000000142
Data for Quality Management

Background: Management theories of learning and experience curve effects state that greater levels of scale produce learnings and improved performance. In cardiovascular care, guidelines suggest that high-volume facilities produce better patient outcomes; yet, there are contradictory findings from the few studies conducted. Our goals were to assess the volume-outcome relationship for interventional cardiovascular care.

Methods: We examined 9360 patients with ST-segment elevation myocardial infarction who underwent percutaneous intervention (PCI). We analyzed 6 years of data (2010-2015) using systematic extracts provided by 33 PCI-capable hospitals in the Dallas Texas region from the National Cardiovascular Data Registry. We stratified hospitals into 3 procedural volume categories (low, intermediate, and high) to identify changes in 2 key outcome metrics (ie, door-to-balloon times and mortality). Multivariate analyses and tests of differences were utilized.

Results: Door-to-balloon performance outcome was significantly different between volume categories, with the highest-volume hospitals performing significantly better than intermediate- and low-volume hospitals (47, 60, and 75 minutes, respectively; P < .001). Mortality followed a similar pattern, with a 3.3% unadjusted absolute lower mortality rate for the high-volume hospitals. Multivariate regressions confirm that volume is statistically significant in both mortality and treatment times.

Conclusions: Higher-volume PCI hospitals have 37% shorter treatment times and 53% lower mortality rates than smaller facilities. This study provides evidence of a positive volume-outcome relationship in interventional cardiovascular care.

The University of Texas Health Science Center, Houston (Drs Langabeer and Kim); and Metropolitan State University, Denver, Colorado (Dr Helton).

Correspondence: James R. Langabeer II, PhD, The University of Texas Health Sciences Center, 7000 Fannin St, Ste 600, Houston, TX 77030 (

The primary author received partial funding from the American Heart Association for this research. The other authors declare no conflicts of interest.

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