Drug-eluting stents in multivessel coronary artery disease: cost effectiveness and clinical outcomes

Utilization of Emergency and Hospitalization Care after Coronary Artery Bypass Surgery for Patients with Ischemic Heart Disease

This retrospective follow-up study explored the status of patients with myocardial infarction with regard to the likelihood of being readmitted to the hospital within 30 days after undergoing coronary artery bypass surgery (CABG) and their survival status within one year of the procedure.The rate of readmission within 30 days was 10.7% (167/1,575), primarily due to surgical wound infection (11.3% of readmission cases), ischemic heart disease (10.3%), and heart failure (8.7%). The readmission group consisted mainly of older males with a high comorbidity index. No significant differences existed between the two groups with regard to case distribution, hospital level, tenure of physicians, or teaching status of the hospitals. Most subsequent emergency department visits one month after surgery involved older male patients with a high comorbidity index. Compared to patients in the non-emergency group, those in the emergency group had longer hospital stays but lower mortality rates. Males constituted a higher proportion of survivors at one year post CABG, with age and comorbidity index being the primary variables affecting the risk of death.The National Health Insurance may adopt the policy of increasing payments for medical institutions that avoid readmission within 30 days post CABG in order to encourage better patient care and avoid the costs associated with readmission.

Appropriateness of elective percutaneous coronary intervention and impact of government health insurance scheme - A tertiary centre experience from Western India

BACKGROUND

There is a dearth of data regarding the appropriateness of elective percutaneous coronary intervention (PCI) in a limited-resource country such as India. In an attempt to rationalise the use of PCI, Appropriate Use Criteria (AUC) were developed for cardiovascular care in the USA. In the Indian context, considering the high prevalence of coronary artery disease, the dramatic rise in the number of revascularization procedures and an increasing role of government/private reimbursements, application of AUC could potentially guide policy to optimize the utilization of resources and the benefit-risk ratio for individual patients.

OBJECTIVES

The study sought to determine the overall and year-wise trends in the appropriateness of elective PCI using the AUC and also understand the impact of the government health insurance scheme (GHIS).

MATERIAL AND METHODS

The inpatient records of all patients undergoing elective PCI, at a single large tertiary care centre in Western India, from January 2009 to December 2014 were retrospectively analysed (n=972, 759 males, 213 females) by a neutral observer. The AUC scores and subsequent ranking were calculated using the dedicated web-based software and each PCIwas ranked as either 'appropriate', 'uncertain' or 'inappropriate'. Elective PCI performed within a month after the index acute coronary syndrome (ACS) was considered as 'ACS' while applying the AUC. All other indications were considered as 'non-ACS'. Nearly 95% of elective PCI performed after July 2012 were covered under theGHIS and therefore the period January 2009-June 2012 was compared with the July 2012- December 2014 to assess the impact of this scheme.

RESULTS

A total of 894 elective PCI (379 and 515 PCI in the ACS setting and non-ACS setting respectively) performed on 857 patients were analysed. The elective PCI performed in the pre-GHIS and GHIS period were 458 and 436 respectively. As per AUC, 352 (39.6 ± 4.4 %) of the overall elective PCI were ranked as 'appropriate', while 487 (55.3 ± 4.1 %) cases as 'uncertain' and 55 (5.1 ± 0.6 %) cases as 'inappropriate'. An overall year-wise temporal trend in the proportion of cases in any of the AUC rankings did not show any significant trends(p > 0.05). However, 80.4 ± 7.3 % of elective PCI in the ACS setting were categorised as 'appropriate' and 82.6 ± 6.9 % of elective PCI in non-ACS setting were ranked as 'uncertain'. With state-wide implementation of the GHIS, the total number of elective PCI increased by 50% (436 in the 3½ year pre-GHIS study period as against 458 in the 2½ year GHIS study period). The introduction of GHIS led to a marginal increase (p > 0.05) in the average annual number of elective PCI in non-ACS setting as opposed to a 120% rise in the number of elective PCI done in the ACS setting (p < 0.001) and the delay in performing PCI after coronary angiogram reduced from 55.8 ± 43.6 days to 33 ± 22.9 days (p < 0.01). Also, the ratio of men: women undergoing elective PCI rationalised from 5.4:1 to 2.7:1 (p < 0.001). With the introduction of the GHIS, the share of 'inappropriate' elective PCI in the ACS setting increased from 1.34 % to 4.81 % (p =0.065). However, there was also a fall in 'appropriate' elective PCI in the non-ACS setting from 15.0 ± 3.2% to 7 ± 1.6% (p < 0.001).

CONCLUSION

On applying the 2012 updated AUC, about 5 % of overall elective PCI were deemed as 'inappropriate'. About four in every five elective PCI in the non-ACS setting were of 'uncertain' appropriateness. The implementation of the GHIS not only significantly reduced the gender bias and delay in seeking interventional coronary care but also led to a significant rise in the proportion of PCI performed in the ACS setting. However, there was also a rise in 'inappropriate' PCI in the ACS setting and a significant fall in 'appropriate' PCI in the non-ACS setting after introduction of the GHIS..

Recovery of Left Ventricular Function After Percutaneous Coronary Intervention Compared to Coronary Artery Bypass Grafting in Patients with Multi-Vessel Coronary Disease and Left Ventricular Dysfunction

Recovery of left ventricular (LV) function after revascularization has been described for coronary artery bypass grafting (CABG); however, LV recovery after percutaneous coronary intervention (PCI), and how it compares to CABG has not been well described in the literature. The aim of this single center retrospective study was to evaluate LV recovery in patients with severely reduced LV function undergoing PCI compared to those undergoing CABG. Patients with LV ejection fraction (LVEF) < 40% and multivessel coronary artery disease (CAD) undergoing revascularization with either CABG (n=16) or PCI (n=176), and with 12 months of follow up data were included in the study. LVEF at baseline exhibited significant differences between PCI (28.5 ± 8.0) and CABG (24.2 ± 6.8) groups (P=.05). LVEF recovery at 6-month follow up showed no difference between PCI and CABG groups. LVEF recovery differences at one-year follow-up was significantly different between PCI (4.82) and CABG (15.25) groups (P=.005). Patients with severely reduced LV function undergoing multivessel PCI had a statistically significant increase in LVEF over time; however patients undergoing CABG demonstrated greater gains in LVEF over the same time period. Surgical revascularization with CABG may be a procedure of choice in patients with depressed LV function and multivessel CAD.