Bigger Primary PCI Centers May Be Better, Danish Study Suggests
Although PCI centers must unequivocally perform a minimum number of annual procedures, a single-center study published online November 25, 2014, ahead of print in EuroIntervention questions the concept of a maximum desirable capacity that is found in international guidelines.
“Whilst the spreading of [primary
PCI] initially demanded the creation of new centers, the present study suggests
that resources can be utilized better by merging neighboring centers, without
negative effects on quality of care,” according to the authors.
Mikkel Malby Schoos, MD, PhD, of Rigshospitalet (Copenhagen, Denmark), and colleagues outline a merger that involved moving all cardiothoracic surgery and acute invasive cardiology services at 2 centers to their institution in June 2011, creating a “mega” center serving 2.5 million people throughout 10,000 km2 and performing approximately 1,000 primary PCIs annually. Rigshospitalet has 4 dedicated PCI suites and 1 hybrid cath lab.
“It is currently stated that the optimal catchment population for a [primary PCI center] ranges from 300,000-1,100,000 inhabitants, resulting in ~200-800 [primary PCI] procedures/year/center, while a higher volume could result in an overload of the center,” the authors note. “However, current guidelines are not specific regarding the optimal… size and are based on consensus and clinical practice rather than specific studies.”
The investigators linked data from national registries with their in-hospital data on 2,066 consecutive STEMI patients treated with primary PCI before and after the merger from January 12, 2009, to January 12, 2012. About 300 patients were transferred via helicopter, and no fibrinolytic or pharmacoinvasive therapy was used.
“Mega” Center Improves Care
The creation of the “mega” center resulted in a 102% increase in the number of primary PCIs performed. Only 1 vessel was reperfused in most cases (93.2%), and procedural success was high (93.7%). The proportion of patients with acute indications rose from before to after the merger (23.7% to 40.8%). Of those with acute indications, the percentage with a primary PCI indication increased, as well (66.3% to 70.1%).
Door-to-balloon, ECG-to-balloon, and symptom-to-balloon times decreased by 1, 20, and 32 minutes, respectively, after the merger (table 1).
These delays were reduced even when excluding patients from the secondary center after the merger.
Overall, pre-hospital triage with direct transfer to the primary PCI center was achieved in 64% of patients. Among those, 82.7% were treated within 120 minutes of pre-hospital ECG recording.
All-cause mortality at 30 days was similar before and after the merger (6.4% vs 6.2%; log-rank P = .525). Multivariable analysis identified the following independent predictors of mortality:
- Older age
- Female sex
- Lower systolic BP
- Higher heart rate
- Killip class > 2
- Preprocedural TIMI flow 0/1
- Multiple treated vessels
Population Size Not Determining Factor for Quality Care
Dr. Schoos and colleagues emphasize that a “mega” center is capable of “providing high-quality treatment, measured by internationally recognized standard quality parameters of [primary PCI]…. Our results demonstrate that the feared overload of a [primary PCI] center by catchment populations > 1 million people is unjustified, but rather is dependent on pre- and in-hospital organization.”
With small, rural hospitals closing or merging with larger facilities across the world, the current model reflects “highly specialized departments at greater distances from local injury sites,” they write. “This calls for an efficient prehospital phase.”
It ultimately comes down to “governance, proper training, resources, and prehospital triage, rather than catchment population size and STEMI incidence” when determining quality of care, the authors conclude.
Note: Two of the study’s coauthors are faculty members of the Cardiovascular Research Foundation, which owns and operates TCTMD.
Source:
Schoos MM, Pedersen F, Holmvang L,
et al. Optimal catchment area and primary PCI center volume revisited: a
single-center experience in transition from high-volume center to “mega center”
for patients with ST-segment elevation myocardial infarction. EuroIntervention. 2014;Epub ahead of
print.
Related Stories:
Yael L. Maxwell is Senior Medical Journalist for TCTMD and Section Editor of TCTMD's Fellows Forum. She served as the inaugural…
Read Full BioDisclosures
- Dr. Schoos reports no relevant conflicts of interest.
Comments