Association between hospital procedure volume and early complications after pacemaker implantation: results from a large, unselected, contemporary cohort of the German nationwide obligatory external quality assurance programme.
OBJECTIVE
Several studies demonstrated an inverse relationship between cardioverter-defibrillator implantation volume and complication rates, suggesting better outcomes for higher volume centres. However, the association of institutional procedural volume with patient outcomes for permanent pacemaker (PPM) implantation remains less known, especially in decentralized implantation systems.


RESULTS
We performed retrospective examination of data on patients undergoing PPM from the German obligatory quality assurance programme (2007-12) to evaluate the relationship of hospital PPM volume (categorized into quintiles of their mean annual volume) with risk-adjusted in-hospital surgical complications (composite of pneumothorax, haemothorax, pericardial effusion, or pocket haematoma, all requiring intervention, or device infection) and pacemaker lead dislocation. Overall 430 416 PPM implantations were documented in 1226 hospitals. Systems included dual (72.8%) and single (25.8%) chamber PPM and cardiac resynchronization therapy (CRT) devices (1.1%). Complications included surgical (0.92%), and ventricular (0.99%), and atrial (1.22%) lead dislocation. Despite an increase in relatively complex procedures (dual chamber, CRT), there was a significant decrease in the procedural and fluoroscopy times and complications from lowest to highest implantation volume quintiles (P for trend <0.0001). The greatest difference was observed between the lowest (1-50 implantations/year-reference group) and the second-lowest (51-90 implantations/year) quintile: surgical complications [odds ratio (OR) 0.69; confidence interval (CI) 0.60-0.78], atrial lead dislocations (OR 0.69; CI 0.59-0.80), and ventricular lead dislocations (OR 0.73; CI 0.63-0.84).


CONCLUSIONS
Hospital annual PPM volume was directly related to indication-based implantation of relatively more complex PPM and yet inversely with procedural times and rates of early surgical complications and lead dislocations. Thus, our data suggest better performance and lower complications with increasing procedural volume.
CCB, Cardioangiologisches Centrum Bethanien, Im Pruefling 23, Frankfurt a.M. D-60389, Germany b.nowak@ccb.de.
Bernd
B
Nowak
AQUA-Institute, Göttingen, Germany.
Karl
K
Tasche
AQUA-Institute, Göttingen, Germany.
Linda
L
Barnewold
AQUA-Institute, Göttingen, Germany.
Günther
G
Heller
CCB, Cardioangiologisches Centrum Bethanien, Im Pruefling 23, Frankfurt a.M. D-60389, Germany.
Boris
B
Schmidt
CCB, Cardioangiologisches Centrum Bethanien, Im Pruefling 23, Frankfurt a.M. D-60389, Germany.
Stefano
S
Bordignon
CCB, Cardioangiologisches Centrum Bethanien, Im Pruefling 23, Frankfurt a.M. D-60389, Germany.
K R Julian
KR
Chun
CCB, Cardioangiologisches Centrum Bethanien, Im Pruefling 23, Frankfurt a.M. D-60389, Germany.
Alexander
A
Fürnkranz
Duke Clinical Research Institute at Duke University Medical Center, Durham, NC, USA.
Rajendra H
RH
Mehta
D000368:Aged; D000369:Aged, 80 and over; D002304:Cardiac Pacing, Artificial / Q000009:adverse effects* / Q000592:standards*; D016009:Chi-Square Distribution; D005260:Female; D005858:Germany; D061847:Hospitals, High-Volume / Q000592:standards*; D061846:Hospitals, Low-Volume / Q000592:standards*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010043:Outcome and Process Assessment, Health Care / Q000592:standards*; D010138:Pacemaker, Artificial / Q000009:adverse effects* / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000592:standards*; D058996:Quality Improvement / Q000592:standards; D019984:Quality Indicators, Health Care / Q000592:standards*; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
Implantation volume; Lead dislocation; Pacemaker implantation complications; Quality assurance