Likelihood of receiving PCI at low-volume center increasing, regardless of race
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Statewide data from California show an increased likelihood of undergoing PCI at a low-volume center over 8 years regardless of race, income or insurance status, researchers reported.
“Everyone — not just vulnerable socioeconomic status groups — is at increased risk for undergoing PCI at a low-volume hospital,” Christina Wang, MD, resident physician at the University of California, San Francisco, told Healio. “However, not all low-volume hospitals are created equal. Black and Hispanic patients, patients with Medicaid and low-income patients are still more likely over time to be receiving PCI at a low-income, low-volume hospital, as opposed to white patients, privately insured patients or high-income patients. The latter are more likely to receive care at low-volume PCI hospitals in high-income areas.”
PCI hospitals by volume
In a retrospective study, Wang and colleagues analyzed data from 374,066 hospitalized patients in California receiving PCI from 2010 to 2018, using nonpublic data from the Department of Health Care Access and Information, which includes discharges from every inpatient encounter from every acute care hospital in California. The primary outcome was the likelihood of PCI discharges at a low-volume hospital, defined as less than 150 PCI procedures per year. Secondary outcomes included whether this likelihood varied across socioeconomic groups and across low-volume hospitals stratified by high or low ZIP code median income.
The findings were published in PLOS ONE.
The total number of hospitals performing PCI increased by 22 hospitals across 9 years, from 153 in 2010 to 175 in 2018. More than half of visits across the cohort (51.3%) were covered by Medicare as opposed to another form of insurance.
Researchers found that the proportion of PCI discharges from low-volume hospitals increased from 5.4% to 11% during the study period. Across all sociodemographic groups, any patient was more likely to visit a low-volume hospital over time (P < .001). In analyses stratified by race, Hispanic patients were more likely to receive PCI at a low-volume hospital vs. white patients in 2010, with a 166% higher gap in 2018.
Gaps in relative risk for receiving PCI at a low-volume center between Black, Hispanic and Asian patients vs. white patients increased over time; however, the gap between patients with private vs. public or no insurance and high- vs. low-income decreased (P for interaction < .001).
In assessing low-income ZIP codes, researchers found that patients with Medicaid were initially more likely to visit low-volume hospitals vs. patients with private insurance; however, by 2018, this gap reversed and increased by 500%. Additionally, patients with low income were more likely to receive PCI at a low-volume center vs. those with high income in all study years.
Implications of new PCI centers
“It was surprising that patients with advantageous socioeconomic status are also more likely to receive PCI at low-volume hospitals over time,” Wang told Healio. “This is important because there are several studies suggesting lower volume can lead to lower quality of PCI, though we do not explore this issue in our study.”
Wang said it is important to assess whether there is an association between low-volume centers and outcomes such as death, complications from PCI or hospital length of stay.
“From a policy perspective, it would be important to examine the implications of placement of new PCI centers and the income of the region,” Wang told Healio. “For example, in low-income areas, a PCI center would improve access; however, we would need to consider the possible detrimental outcomes, if any, of low-volume hospitals. In a high-income area, a new center could lower per-hospital PCI volume.”
For more information:
Christina Wang, MD, can be reached at christina.wang@ucsf.edu; Twitter: @christinawang14.
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