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Zhou S, Zhang Y, Dong X, Ma J, Li N, Shi H, Smith SC, Jin Y, Xu M, Xiang D, Zheng ZJ, Huo Y. Regional variations in management and outcomes of patients with acute coronary syndrome in China: Evidence from the National Chest Pain Center Program. Sci Bull (Beijing) 2024; 69:1302-1312. [PMID: 38519397 DOI: 10.1016/j.scib.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/25/2023] [Accepted: 12/19/2023] [Indexed: 03/24/2024]
Abstract
Regional variations in acute coronary syndrome (ACS) management and outcomes have been an enormous public health issue. However, studies have yet to explore how to reduce the variations. The National Chest Pain Center Program (NCPCP) is the first nationwide, hospital-based, comprehensive, continuous quality improvement program for improving the quality of care in patients with ACS in China. We evaluated the association of NCPCP and regional variations in ACS healthcare using generalized linear mixed models and interaction analysis. Patients in the Western region had longer onset-to-first medical contact (FMC) time and time stay in non-percutaneous coronary intervention (PCI) hospitals, lower rates of PCI for ST-elevation myocardial infarction (STEMI) patients, and higher rates of medication usage. Patients in Central regions had relatively lower in-hospital mortality and in-hospital heart failure rates. Differences in the door-to-balloon time (DtoB) and in-hospital mortality between Western and Eastern regions were less after accreditation (β = -8.82, 95% confidence interval (CI) -14.61 to -3.03; OR = 0.79, 95%CI 0.70 to 0.91). Similar results were found in differences in DtoB time, primary PCI rate for STEMI between Central and Eastern regions. The differences in PCI for higher-risk non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients among different regions had been smaller. Additionally, the differences in medication use between Eastern and Western regions were higher after accreditation. Regional variations remained high in this large cohort of patients with ACS from hospitals participating in the NCPCP in China. More comprehensive interventions and hospital internal system optimizations are needed to further reduce regional variations in the management and outcomes of patients with ACS.
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Affiliation(s)
- Shuduo Zhou
- Department of Global Health, Peking University School of Public Health, Beijing 100191, China; Institute for Global Health and Development, Peking University, Beijing100871, China
| | - Yan Zhang
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China
| | - Xuejie Dong
- Department of Global Health, Peking University School of Public Health, Beijing 100191, China; Institute for Global Health and Development, Peking University, Beijing100871, China
| | - Junxiong Ma
- Department of Global Health, Peking University School of Public Health, Beijing 100191, China; Institute for Global Health and Development, Peking University, Beijing100871, China
| | - Na Li
- Department of Global Health, Peking University School of Public Health, Beijing 100191, China; Institute for Global Health and Development, Peking University, Beijing100871, China
| | - Hong Shi
- Chinese Medical Association, Beijing 100052, China
| | - Sidney C Smith
- Division of Cardiovascular Medicine, School of Medicine, University of North Carolina at Chapel Hill, North Carolina 27599-3140, USA
| | - Yinzi Jin
- Department of Global Health, Peking University School of Public Health, Beijing 100191, China; Institute for Global Health and Development, Peking University, Beijing100871, China
| | - Ming Xu
- Department of Global Health, Peking University School of Public Health, Beijing 100191, China; Institute for Global Health and Development, Peking University, Beijing100871, China
| | - Dingcheng Xiang
- Department of Cardiology, General Hospital of Southern Theater Command of PLA, Guangzhou 510010, China.
| | - Zhi-Jie Zheng
- Department of Global Health, Peking University School of Public Health, Beijing 100191, China; Institute for Global Health and Development, Peking University, Beijing100871, China.
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China.
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Shen YC, Krumholz HM, Hsia RY. Do PCI Facility Openings and Closures Affect AMI Outcomes Differently in High- vs Average-Capacity Markets? JACC Cardiovasc Interv 2023; 16:1129-1140. [PMID: 37225284 PMCID: PMC10229059 DOI: 10.1016/j.jcin.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Disparities in access to percutaneous coronary intervention (PCI) for patients with acute myocardial infarction may result from openings and closures of PCI-providing hospitals, potentially leading to low hospital PCI volume, which is associated with poor outcomes. OBJECTIVES The authors sought to determine whether openings and closures of PCI hospitals have differentially impacted patient health outcomes in high- vs average-capacity PCI markets. METHODS In this retrospective cohort study, the authors identified PCI hospital availability within a 15-minute driving time of zip code communities. The authors categorized communities by baseline PCI capacity and identified changes in outcomes associated with PCI-providing hospital openings and closures using community fixed-effects regression models. RESULTS From 2006 to 2017, 20% and 16% of patients in average- and high-capacity markets, respectively, experienced a PCI hospital opening within a 15-minute drive. In average-capacity markets, openings were associated with a 2.6 percentage point decrease in admission to a high-volume PCI facility; high-capacity markets saw an 11.6 percentage point decrease. After an opening, patients in average-capacity markets experienced a 5.5% and 7.6% relative increase in likelihood of same-day and in-hospital revascularization, respectively, as well as a 2.5% decrease in mortality. PCI hospital closures were associated with a 10.4% relative increase in admission to high-volume PCI hospitals and a 1.4 percentage point decrease in receipt of same-day PCI. There was no change observed in high-capacity PCI markets. CONCLUSIONS After openings, patients in average-capacity markets derived significant benefits, whereas those in high-capacity markets did not. This suggests that past a certain threshold, facility opening does not improve access and health outcomes.
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Affiliation(s)
- Yu-Chu Shen
- Naval Postgraduate School, Monterey, California, USA; National Bureau of Economic Research, Cambridge Massachusetts, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, California, USA; Philip R. Lee Institute for Health Policy Studies, University of California-San Francisco, San Francisco, California, USA.
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3
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Wong MYZ, Yap JJL, Chih HJ, Yan BPY, Fong AYY, Beltrame JF, Wijaya IP, Nguyen HTT, Brennan AL, Reid CM, Yeo KK. Regional differences in percutaneous coronary intervention outcomes in STEMI patients with diabetes: The Asia-Pacific evaluation of cardiovascular therapies (ASPECT) collaboration. Int J Cardiol 2023; 371:84-91. [PMID: 36220505 DOI: 10.1016/j.ijcard.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/13/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Diabetes is associated with poorer outcomes and increased complication rates in STEMI patients undergoing percutaneous coronary intervention (PCI). Data are notably lacking in the Asia-Pacific region. We report the overall association of Diabetes with clinical characteristics and outcomes in STEMI patients undergoing PCI across the Asia-Pacific, with a particular focus on regional differences. METHODOLOGY The Asia Pacific Evaluation of Cardiovascular Therapies (ASPECT) collaboration consists of data from various PCI registries across Australia, Hong Kong, Singapore, Malaysia, Indonesia and Vietnam. Clinical characteristics, lesion characteristics, and outcomes were provided for STEMI patients. Key outcomes included 30-day overall mortality and major adverse cardiovascular events (MACE). RESULTS A total of 12,144 STEMI patients (mean(SD) age 59.3(12.3)) were included, of which 3912 (32.2%) had diabetes. Patients with diabetes were likely to have a higher baseline risk profile, poorer clinical presentation, and more complex lesion patterns (all p < 0.05). Across all regions, patients with diabetes had a higher rate of 30-day mortality and MACE (all p < 0.05). After multivariable adjustment, diabetes was significantly associated with both increased 30-day mortality (9.6%vs 5.5%, OR 1.79 [95% CI 1.40-2.30]) and MACE (13.3% vs 8.6%, R 1.73 [1.44-2.08]). The association between diabetes and 30-day MACE varied by region (pinteraction = 0.041), with the association (OR) ranging from 1.34 [1.08-1.67] in Malaysia, to 2.39 [1.66-3.45] in Singapore. CONCLUSIONS Diabetes portends poorer clinical outcomes in STEMI patients undergoing PCI in the Asia-Pacific with regional variations noted. The development of effective preventative measures and interventional strategies targetted at this high-risk group is crucial.
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Affiliation(s)
- Mark Y Z Wong
- Department of Cardiology, National Heart Centre Singapore, Singapore; School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jonathan J L Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Hui Jun Chih
- School of Population Health, Curtin University, Perth, Australia
| | - Bryan P Y Yan
- Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | | | - John F Beltrame
- Coronary Angiography Registry Database of South Australia (CARDOSA) registries, Australia
| | - Ika Prasetya Wijaya
- Cardiology Division, Universitas Indonesia, Ciptomangunkusumo General Hospital, Indonesia
| | - Hoai T T Nguyen
- Vietnam National Heart Institute, Bach Mai Hospital, Hanoi, Viet Nam
| | - Angela L Brennan
- Melbourne Interventional Group, Melbourne, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Christopher M Reid
- School of Population Health, Curtin University, Perth, Australia; Melbourne Interventional Group, Melbourne, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore.
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Everhart A, Desai NR, Dowd B, Herrin J, Higuera L, Jeffery MM, Jena AB, Ross JS, Shah ND, Smith LB, Karaca-Mandic P. Physician variation in the de-adoption of ineffective statin and fibrate therapy. Health Serv Res 2021; 56:919-931. [PMID: 33569804 DOI: 10.1111/1475-6773.13630] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To describe physicians' variation in de-adopting concurrent statin and fibrate therapy for type 2 diabetic patients following a reversal in clinical evidence. DATA SOURCES We analyzed 2007-2015 claims data from OptumLabs® Data Warehouse, a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data. STUDY DESIGN We modeled fibrate use among Medicare Advantage and commercially insured type 2 diabetic statin users before and after the publication of the ACCORD lipid trial, which found statins and fibrates were no more effective than statins alone in reducing cardiovascular events among type 2 diabetic patients. We modeled fibrate use trends with physician random effects and physician characteristics such as age and specialty. DATA EXTRACTION We identified patient-year-quarters with one year of continuous insurance enrollment, type 2 diabetes diagnoses, and fibrate use. We designated the physician most responsible for patients' diabetes care based on evaluation and management visits and prescriptions of glucose-lowering drugs. PRINCIPAL FINDINGS Fibrate use increased by 0.12 percentage points per quarter among commercial patients (95% CI, 0.10 to 0.14) and 0.17 percentage points per quarter among Medicare Advantage patients (95% CI, 0.13 to 0.20) before the trial and then decreased by 0.16 percentage points per quarter among commercial patients (95% CI, -0.18 to -0.15) and 0.05 percentage points per quarter among Medicare Advantage patients (95% CI, -0.06 to -0.03) after the trial. However, 45% of physicians treating commercial patients and 48% of physicians treating Medicare Advantage patients had positive trends in prescribing following the trial. Physicians' characteristics did not explain their variation (pseudo R2 = 0.000). CONCLUSION On average, physicians decreased fibrate prescribing following the ACCORD lipid trial. However, many physicians increased prescribing following the trial. Observable physician characteristics did not explain variations in prescribing. Future research should examine whether physicians vary similarly in other de-adoption settings.
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Affiliation(s)
- Alexander Everhart
- University of Minnesota, Minneapolis, Minnesota, USA.,OptumLabs Visiting Fellow, Eden Prairie, Minnesota, USA
| | - Nihar R Desai
- Yale School of Medicine, Charlottesville, Virginia, USA
| | - Bryan Dowd
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Jeph Herrin
- Yale School of Medicine, Charlottesville, Virginia, USA
| | - Lucas Higuera
- University of Minnesota, Minneapolis, Minnesota, USA.,Medtronic Plc, Mounds View, Minnesota, USA
| | | | - Anupam B Jena
- Harvard Medical School, Boston, Massachusetts, USA.,Massachusetts General Hospital, Boston, Massachusetts, USA.,National Bureau of Economic Research, Cambridge, Massachusetts, USA
| | - Joseph S Ross
- Yale School of Medicine, Charlottesville, Virginia, USA
| | | | | | - Pinar Karaca-Mandic
- University of Minnesota, Minneapolis, Minnesota, USA.,National Bureau of Economic Research, Cambridge, Massachusetts, USA
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5
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Lotun K, Truong HT, Cha KC, Alsakka H, Gianotto-Oliveira R, Smith N, Rao P, Bien T, Chatelain S, Kern MC, Hsu CH, Zuercher M, Kern KB. Cardiac Arrest in the Cardiac Catheterization Laboratory: Combining Mechanical Chest Compressions and Percutaneous LV Assistance. JACC Cardiovasc Interv 2020; 12:1840-1849. [PMID: 31537284 DOI: 10.1016/j.jcin.2019.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/29/2019] [Accepted: 05/14/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the optimal treatment approach for cardiac arrest (CA) occurring in the cardiac catheterization laboratory. BACKGROUND CA can occur in the cath lab during high-risk percutaneous coronary intervention. While attempting to correct the precipitating cause of CA, several options are available to maintain vital organ perfusion. These include manual chest compressions, mechanical chest compressions, or a percutaneous left ventricular assist device. METHODS Eighty swine (58 ± 10 kg) were studied. The left main or proximal left anterior descending artery was occluded. Ventricular fibrillation (VFCA) was induced and circulatory support was provided with 1 of 4 techniques: either manual chest compressions (frequently interrupted), mechanical chest compressions with a piston device (LUCAS-2), an Impella 2.5 L percutaneously placed LVAD, or the combination of mechanical chest compressions and the percutaneous left ventricular assist device. The study protocol included 12 min of left main coronary occlusion, reperfusion, with defibrillation attempted after 15 min of VFCA. Primary outcome was favorable neurological function (CPC 1 or 2) at 24 h, while secondary outcomes included return of spontaneous circulation and hemodynamics. RESULTS Manual chest compressions provided fewer neurologically intact surviving animals than the combination of a mechanical chest compressor and a percutaneous LVAD device (0% vs. 56%; p < 0.01), while no difference was found between the 2 mechanical approaches (28% vs. 35%: p = 0.75). Comparing integrated coronary perfusion pressure showed sequential improvement in hemodynamic support with mechanical devices (401 ± 230 vs. 1,337 ± 905 mm Hg/s; p = 0.06). CONCLUSIONS Combining 2 mechanical devices provided superior 24-h survival with favorable neurological recovery compared with manual compressions during moderate duration VFCA associated with an acute coronary occlusion in the animal catheterization laboratory.
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Affiliation(s)
- Kapildeo Lotun
- Department of Medicine, University of Arizona Sarver Heart Center, Tucson, Arizona
| | - Huu Tam Truong
- Department of Medicine, University of Arizona Sarver Heart Center, Tucson, Arizona
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju-si, Republic of Korea
| | - Hanan Alsakka
- Department of Medicine, University of Arizona Sarver Heart Center, Tucson, Arizona
| | - Renan Gianotto-Oliveira
- Department of Medicine, Heart Institute (InCor), School of Medicine, Sao Paulo University, Sao Paulo, Brazil
| | - Nicole Smith
- Department of Medicine, University of Arizona Sarver Heart Center, Tucson, Arizona
| | - Prashant Rao
- Department of Medicine, University of Arizona Sarver Heart Center, Tucson, Arizona
| | - Tyler Bien
- Department of Medicine, University of Arizona Sarver Heart Center, Tucson, Arizona
| | - Shaun Chatelain
- Department of Medicine, University of Arizona Sarver Heart Center, Tucson, Arizona
| | - Matthew C Kern
- Department of Medicine, University of Arizona Sarver Heart Center, Tucson, Arizona
| | - Chiu-Hsieh Hsu
- University of Arizona College of Public Health, Tucson, Arizona
| | - Mathias Zuercher
- Department of Anesthesiology, University of Basel, Basel, Switzerland
| | - Karl B Kern
- Department of Medicine, University of Arizona Sarver Heart Center, Tucson, Arizona.
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Kataruka A, Maynard CC, Kearney KE, Mahmoud A, Bell S, Doll JA, McCabe JM, Bryson C, Gurm HS, Jneid H, Virani SS, Lehr E, Ring ME, Hira RS. Temporal Trends in Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting: Insights From the Washington Cardiac Care Outcomes Assessment Program. J Am Heart Assoc 2020; 9:e015317. [PMID: 32456522 PMCID: PMC7429009 DOI: 10.1161/jaha.119.015317] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background Patient selection and outcomes for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) have changed over the past decade. However, there is limited information on outcomes for both revascularization strategies in the same population. The study evaluated temporal changes in risk profile, procedural characteristics, and clinical outcomes for PCI‐ and CABG‐treated patients. Methods and Results We analyzed all PCI and isolated CABG between 2005 and 2017 in nonfederal hospitals in Washington State. Descriptive analysis was performed to evaluate temporal changes in risk profile and, risk‐adjusted in‐hospital mortality. Over the study period, 178 474 PCI and 36 592 CABG procedures were performed. PCI and CABG volume decreased by 2.9% and 22.6%, respectively. Compared with 2005–2009, patients receiving either form of revascularization between 2014 and 2017 had a higher prevalence of comorbidities including diabetes mellitus and hypertension and dialysis. Presentation with ST‐segment–elevation myocardial infarction (17% versus 20%) and cardiogenic shock (2.4% versus 3.4%) increased for patients with PCI compared with CABG. Conversely, clinical acuity decreased for patients receiving CABG over the study period. From 2005 to 2017, mean National Cardiovascular Data Registry CathPCI mortality score increased for patients treated with PCI (20.1 versus 22.4, P<0.0001) and decreased for patients treated with CABG (18.8 versus 17.8, P<0.0001). Adjusted observed/expected in‐hospital mortality ratio increased for PCI (0.98 versus 1.19, P<0.0001) but decreased for CABG (1.21 versus 0.74, P<0.0001) over the study period. Conclusions Clinical acuity increased for patients treated with PCI rather than CABG. This resulted in an increase in adjusted observed/expected mortality ratio for patients undergoing PCI and a decrease for CABG. These shifts may reflect an increased use of PCI instead of CABG for patients considered to be at high surgical risk.
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Affiliation(s)
- Akash Kataruka
- Division of Cardiology University of Washington Seattle WA
| | - Charles C Maynard
- Department of Health Services University of Washington Seattle WA.,Cardiac Care Outcomes Assessment Program Foundation for Health Care Quality Seattle WA
| | | | - Ahmed Mahmoud
- Division of Cardiology University of Washington Seattle WA
| | - Sean Bell
- Department of Medicine University of Washington Seattle WA
| | - Jacob A Doll
- Division of Cardiology University of Washington Seattle WA.,VA Puget South Health Care System Seattle WA
| | - James M McCabe
- Division of Cardiology University of Washington Seattle WA
| | | | | | - Hani Jneid
- Division of Cardiology Michael E. DeBakey VA& Baylor College of Medicine Houston TX
| | - Salim S Virani
- Division of Cardiology Michael E. DeBakey VA& Baylor College of Medicine Houston TX
| | - Eric Lehr
- Department of Cardiac Surgery Swedish Heart & Vascular Institute Seattle WA
| | | | - Ravi S Hira
- Division of Cardiology University of Washington Seattle WA.,Cardiac Care Outcomes Assessment Program Foundation for Health Care Quality Seattle WA
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7
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Gibbons RJ, Weintraub WS, Brindis RG. Moving from volume to value for revascularization in stable ischemic heart disease: A review. Am Heart J 2018; 204:178-185. [PMID: 30077336 DOI: 10.1016/j.ahj.2018.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/02/2018] [Indexed: 01/09/2023]
Abstract
IMPORTANCE Although percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are both commonly employed in the treatment of stable ischemic heart disease (SIHD), their ability to reduce subsequent heart attacks and death is currently in question. These procedures will come under increasing scrutiny as the healthcare reimbursement system moves away from the traditional fee for service model in favor of "pay for value". OBSERVATION Both international and domestic data show wide variability in the use of PCI and CABG in patients with SIHD. There is evidence of ongoing quality improvement over the last 5 years in reducing the use of inappropriate procedures, but there is still room for improvement. We present ideas regarding health policy interventions that might help manage the transition to value-based payments in this area, including improvements in national registries, more rapid revision of appropriate use criteria, shared decision making, and evidence-based management of PCI in SIHD. CONCLUSIONS AND RELEVANCE The use of revascularization procedures in patients with SIHD is potentially a model for how care might be improved with health care policy intervention. We suggest that the status quo, although apparently improved over the last 5 years, is still unacceptable when 25% of hospitals have a rate of unnecessary PCI in patients with SIHD that approaches 25%.
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Revascularization for Stable Ischemic Heart Disease. JACC Cardiovasc Interv 2018; 11:876-878. [DOI: 10.1016/j.jcin.2018.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 03/20/2018] [Indexed: 01/09/2023]
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Chen H, Shi L, Xue M, Wang N, Dong X, Cai Y, Chen J, Zhu W, Xu H, Meng Q. Geographic Variations in In‐Hospital Mortality and Use of Percutaneous Coronary Intervention Following Acute Myocardial Infarction in China: A Nationwide Cross‐Sectional Analysis. J Am Heart Assoc 2018. [PMCID: PMC6015409 DOI: 10.1161/jaha.117.008131] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Prevalence of acute myocardial infarction (AMI) is increasing in China, and AMI has become a major cause of mortality; however, information is very limited about the nationwide geographic and hospital variation in in‐hospital mortality (IHM) and the use of percutaneous coronary intervention (PCI) after AMI. Methods and Results From the Nationwide Hospital Discharge Database of China, we identified 242 866 adult admissions with AMI in 2015 from 1055 tertiary hospitals. We used multivariable logistic regressions to analyze the associations between geographic or hospital characteristics with IHM or PCI use. The national IHM rate was 4.71% (95% confidence interval, 4.62–4.79%). There was a greater risk of mortality in the Northeast (odds ratio [OR]: 1.86), West (OR: 1.73), South (OR: 1.32), and North (OR: 1.14) regions than in the East region of China. Non–teaching hospitals (OR: 1.18) and tertiary level B hospitals (OR: 1.06) were associated with higher IHM rates. The national PCI use rate was 45.3% (95% confidence interval, 45.1–45.5%). Compared with the East region of China, PCI use was lower in the Northeast (OR: 0.50), West (OR: 0.64), North (OR: 0.84), and South (OR: 0.88) regions. Non–teaching hospitals (OR: 0.83) and tertiary level B hospitals (OR: 0.55) were also associated with lower usage rates. There was a significant negative correlation between IHM and PCI use (r=−0.955), and IHM rates for patients with and without PCI both differed by geographic regions. Conclusions There were significant differences in IHM and PCI use among China's tertiary hospitals, linked to both geographic and hospital characteristics. More targeted intervention at national and regional levels is needed to improve access to effective health technologies and, eventually, outcomes following AMI.
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Affiliation(s)
- Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Lizheng Shi
- Department of Global Health Management and Policy, Tulane University, New Orleans, LA
| | - Ming Xue
- Centre for Health Statistics and Information, The National Health and Family Planning Commission of China, Beijing, China
| | - Ni Wang
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Xiao Dong
- School of Biomedical Informatics, The University of Texas Health Science Centre at Houston, TX
| | - Yue Cai
- Centre for Health Statistics and Information, The National Health and Family Planning Commission of China, Beijing, China
| | - Jieqing Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Weiguo Zhu
- Department of Information Management, Department of General Internal Medicine, Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences, Beijing, China
| | - Hua Xu
- School of Biomedical Informatics, The University of Texas Health Science Centre at Houston, TX
| | - Qun Meng
- Centre for Health Statistics and Information, The National Health and Family Planning Commission of China, Beijing, China
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10
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Liang FW, Lu TH, Wu HM, Lee JC, Yin WH. Regional and hospital variations in the extent of decline in the proportion of percutaneous coronary interventions performed for nonacute indications - a nationwide population-based study. BMC Cardiovasc Disord 2017; 17:149. [PMID: 28599642 PMCID: PMC5466717 DOI: 10.1186/s12872-017-0592-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 06/05/2017] [Indexed: 11/26/2022] Open
Abstract
Background The volume and percentage of percutaneous coronary interventions (PCIs) performed for nonacute indications have declined in the United States since 2007. However, little is known if similar trends occurred in Taiwan. Methods We used data from Taiwan National Health Insurance inpatient claims to examine the regional and hospital variations in the extent of decline in the percentage of nonacute indication PCIs from 2007 to 2012. Results The volume of total PCIs persistently increased from 29,032 in 2007 to 35,811 in 2010 and 37,426 in 2012. However, the volume of nonacute indication PCIs first increased from 7916 in 2007 to 9143 in 2009 and then decreased to 8666 in 2012. The percentage of nonacute indication PCIs steadily decreased from 27% in 2007 to 26% in 2009 and then to 23% in 2012, a − 15% change. The extent of decline was largest in the North region (from 27% to 21%, a − 22% change) and least in Kaopin region (from 20% to 18%, a − 13% change). Of the 71 hospitals studied, 14 did not show a decreasing trend. Five of the 14 hospitals even showed an increasing trend, with a percentage change >10% between 2007 and 2012. In 2012, 6 hospitals had a nonacute indication PCI percentage >35%. Conclusions In Taiwan, four-fifths of the hospitals showed a decline in the percentage of nonacute indication PCIs from 2007 to 2012. It is plausible that Taiwanese cardiologists would have been influenced by the recommendations of crucial US trials and guidelines.
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Affiliation(s)
- Fu-Wen Liang
- The NCKU Research Center for Health Data and Department of Public Health, National Cheng Kung University, No. 1, University Road, East District, Tainan, 70101, Taiwan
| | - Tsung-Hsueh Lu
- The NCKU Research Center for Health Data and Department of Public Health, National Cheng Kung University, No. 1, University Road, East District, Tainan, 70101, Taiwan
| | - Hsin-Min Wu
- The NCKU Research Center for Health Data and Department of Public Health, National Cheng Kung University, No. 1, University Road, East District, Tainan, 70101, Taiwan
| | - Jo-Chi Lee
- The NCKU Research Center for Health Data and Department of Public Health, National Cheng Kung University, No. 1, University Road, East District, Tainan, 70101, Taiwan
| | - Wei-Hsian Yin
- Division of Cardiology, Cheng Hsin General Hospital, No. 45, Cheng Hsin Street, Bei-Tou, Taipei, 11220, Taiwan. .,School of Medicine, National Yang Ming University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan.
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Vaez M, Dalén M, Friberg Ö, Nilsson J, Frøbert O, Lagerqvist B, Ivert T. Regional differences in coronary revascularization procedures and outcomes: a nationwide 11-year observational study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2017; 3:243-248. [DOI: 10.1093/ehjqcco/qcx007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/27/2017] [Indexed: 11/14/2022]
Abstract
Abstract
Aims
The study investigated whether regional differences in choice of coronary revascularization affected outcomes in Sweden.
Methods and results
We conducted a prospective nationwide study of outcome in patients undergoing coronary artery bypass grafting (CABG, n = 47 065) or percutaneous coronary intervention (PCI, n = 140 945) from 2001 through 2011, tracked for a median of 5 years. During this period, the proportion of CABG in revascularization procedures decreased nationwide from an average of 38% to 18%e. Three-vessel disease and left main stem coronary artery stenosis were more common among CABG patients than in PCI patients. In both males and females, all-cause mortality was higher in CABG patients than in PCI patients, while repeat PCI was performed more frequently in the PCI group. CABG proportions in 21 counties ranged from 13% to 42% in females and males. The combined outcomes of repeat revascularization, non-fatal acute myocardial infarction, and death during the tracking period was recorded in 151 936 patients without ST-elevation myocardial infarction after PCI (n = 37 820, 36%) and CABG (n = 18 903, 40%). The multivariable adjusted risk of combined outcomes was higher after both PCI and CABG in both females and males in the three quartiles of counties with a smaller proportion of CABG than in the quartile of counties with the highest proportion of CABG. Similar patterns persisted after including only mortality in the analyses.
Conclusion
There are subgroups of patients who have prognostic benefits of CABG in addition to symptomatic improvement that is well documented with both PCI and CABG.
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Affiliation(s)
- Marjan Vaez
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Dalén
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Örjan Friberg
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Sweden
| | - Johan Nilsson
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Ole Frøbert
- Faculty of Health, Department of Cardiology, Örebro University Hospital, Örebro University, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Cardiology Section, Uppsala Clinical, Research Center, Uppsala University, Uppsala, Sweden
| | - Torbjörn Ivert
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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12
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Librero J, Ibañez B, Martínez-Lizaga N, Peiró S, Bernal-Delgado E. Applying spatio-temporal models to assess variations across health care areas and regions: Lessons from the decentralized Spanish National Health System. PLoS One 2017; 12:e0170480. [PMID: 28166233 PMCID: PMC5293276 DOI: 10.1371/journal.pone.0170480] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 01/05/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To illustrate the ability of hierarchical Bayesian spatio-temporal models in capturing different geo-temporal structures in order to explain hospital risk variations using three different conditions: Percutaneous Coronary Intervention (PCI), Colectomy in Colorectal Cancer (CCC) and Chronic Obstructive Pulmonary Disease (COPD). RESEARCH DESIGN This is an observational population-based spatio-temporal study, from 2002 to 2013, with a two-level geographical structure, Autonomous Communities (AC) and Health Care Areas (HA). SETTING The Spanish National Health System, a quasi-federal structure with 17 regional governments (AC) with full responsibility in planning and financing, and 203 HA providing hospital and primary care to a defined population. METHODS A poisson-log normal mixed model in the Bayesian framework was fitted using the INLA efficient estimation procedure. MEASURES The spatio-temporal hospitalization relative risks, the evolution of their variation, and the relative contribution (fraction of variation) of each of the model components (AC, HA, year and interaction AC-year). RESULTS Following PCI-CCC-CODP order, the three conditions show differences in the initial hospitalization rates (from 4 to 21 per 10,000 person-years) and in their trends (upward, inverted V shape, downward). Most of the risk variation is captured by phenomena occurring at the HA level (fraction variance: 51.6, 54.7 and 56.9%). At AC level, the risk of PCI hospitalization follow a heterogeneous ascending dynamic (interaction AC-year: 17.7%), whereas in COPD the AC role is more homogenous and important (37%). CONCLUSIONS In a system where the decisions loci are differentiated, the spatio-temporal modeling allows to assess the dynamic relative role of different levels of decision and their influence on health outcomes.
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Affiliation(s)
- Julián Librero
- Navarrabiomed—Fundación Miguel Servet, Pamplona, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Bilbao, Spain
| | - Berta Ibañez
- Navarrabiomed—Fundación Miguel Servet, Pamplona, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Bilbao, Spain
| | - Natalia Martínez-Lizaga
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Bilbao, Spain
- Instituto Aragonés de Ciencias de la Salud, IIS Aragón, Zaragoza, Spain
| | - Salvador Peiró
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Bilbao, Spain
- Centro Superior de Investigación en Salud Pública (CSISP-FISABIO), Valencia, Spain
| | - Enrique Bernal-Delgado
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Bilbao, Spain
- Instituto Aragonés de Ciencias de la Salud, IIS Aragón, Zaragoza, Spain
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13
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Weintraub WS, Boden WE. Reexamining the Efficacy and Value of Percutaneous Coronary Intervention for Patients With Stable Ischemic Heart Disease. JAMA Intern Med 2016; 176:1190-4. [PMID: 27380178 PMCID: PMC5656233 DOI: 10.1001/jamainternmed.2016.3071] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Percutaneous coronary intervention (PCI) continues to be performed frequently for patients with stable ischemic heart disease, despite uncertain efficacy. Individual randomized trial data and meta-analyses have not demonstrated that PCI in addition to optimal medical therapy reduces the incidence of death or myocardial infarction in patients with stable disease. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial did not show benefit for cardiovascular outcomes or mortality but did find a modest improvement in quality of life that did not persist at 3 years. Long-term follow-up from COURAGE (up to 15 years) found no differences in mortality, consistent with other published literature. How PCI could reduce long-term mortality or prevent myocardial infarction is not clear because sites of future plaque rupture leading to myocardial infarction are unpredictable and PCI can only treat localized anatomic segments of obstructive atherosclerosis. In addition, PCI is expensive, and the value to society of PCI for stable disease has not been demonstrated. The ISCHEMIA trial will assess the role of PCI for stable ischemic heart disease using newer technology and in patients with greater ischemic burden than in COURAGE. After nearly a decade, the COURAGE trial and other studies have given us pause to critically reexamine the role of PCI for patients with stable ischemic heart disease. Until further research can show that PCI can reduce cardiovascular events in these patients, a first-line strategy of optimal medical therapy is known to be safe, effective, and noninferior to PCI, and our practice should more closely follow this strategy.
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Affiliation(s)
- William S Weintraub
- Center for Heart and Vascular Health, Christiana Care Health System, Newark, Delaware
| | - William E Boden
- Department of Medicine, Albany Medical College, Albany, New York
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14
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15
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Kim LK, Looser P, Swaminathan RV, Minutello RM, Wong SC, Girardi L, Feldman DN. Outcomes in patients undergoing coronary artery bypass graft surgery in the United States based on hospital volume, 2007 to 2011. J Thorac Cardiovasc Surg 2016; 151:1686-92. [DOI: 10.1016/j.jtcvs.2016.01.050] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 01/11/2016] [Accepted: 01/26/2016] [Indexed: 11/25/2022]
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16
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Ndrepepa G, Stephan T, Fiedler KA, Guerra E, Kufner S, Kastrati A. Procedure-related bleeding in elective percutaneous coronary interventions. Eur J Clin Invest 2015; 45:263-73. [PMID: 25645583 DOI: 10.1111/eci.12408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 01/19/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Prognostic impact of procedure-related bleeding in patients with stable coronary artery disease (CAD) undergoing elective percutaneous coronary intervention (PCI) remains incompletely investigated. The aim of this study was to investigate the association between peri-PCI bleeding and 1-year outcome of patients with stable CAD. MATERIALS AND METHODS The study included 9035 patients with stable CAD who underwent elective PCI. Bleeding within 30 days of PCI was defined using the Bleeding Academic Research Consortium (BARC) criteria. The primary outcome was 1-year mortality. RESULTS Bleeding occurred in 844 patients (9.3%). Actionable bleeding (BARC class ≥ 2) occurred in 442 patients (4.9%). There were 210 deaths (2.3%) at 1 year following PCI: 41 deaths among patients with bleeding and 169 deaths among patients without bleeding [Kaplan-Meier estimates of mortality, 4.9% and 2.1%; odds ratio = 2.41, 95% confidence interval (CI) 1.73-3.36, P < 0.001]. The association between bleeding and mortality remained significant after adjustment for baseline risk variables (adjusted hazard ratio = 1.87, 95% CI 1.27-2.76, P = 0.002). Bleeding increased the discriminatory power of the model regarding prediction of 1-year mortality (absolute and relative integrated discrimination improvement, 0.006% and 16.3%, respectively, P = 0.001). CONCLUSIONS In patients with stable CAD undergoing elective PCI, the occurrence of bleeding within 30 days of the procedure was associated with increased risk of death at 1 year after PCI. These findings suggest that procedure-related bleeding may contribute to less than optimal results of PCI in terms of mortality reduction in patients with stable CAD.
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Affiliation(s)
- Gjin Ndrepepa
- Deutsches Herzzentrum, Technische Universität, Munich, Germany
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17
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Worden NE, Lindower PD, Burns TL, Chatterjee K, Weiss RM. A second look with prone SPECT myocardial perfusion imaging reduces the need for angiography in patients at low risk for cardiac death or MI. J Nucl Cardiol 2015; 22:115-22. [PMID: 24980454 DOI: 10.1007/s12350-014-9934-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 05/27/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Correction for soft tissue signal attenuation can improve the diagnostic accuracy of single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). The aim of this study was to correlate SPECT-MPI findings with clinical outcomes in patients who underwent stress imaging in the supine position, who also underwent "second look" stress imaging in the prone position. METHODS Patients without perfusion abnormalities were considered Normal (N = 270). Those with apparent supine stress perfusion abnormalities which all resolved during prone imaging formed the Normal-Prone group (N = 309). Patients with matched perfusion abnormalities during both supine and prone stress imaging were considered Abnormal (N = 169). RESULTS During follow-up (187 ± 96 days), utilization rates for invasive coronary angiography were similar for Normal vs Normal-Prone patients (3.5% vs 3.8%; P = NS), but were significantly higher in Abnormal patients (42.4%, P < .0001). Coronary revascularization occurred in 0.78%, 0.64%, and 17.7% of Normal, Normal-Prone, and Abnormal patients, respectively (P < .001). Cardiac death or myocardial infarction occurred in 2.2%, 2.3%, and 6.3% of Normal, Normal-Prone, and Abnormal patients, respectively (P = .02). CONCLUSIONS Second look SPECT-MPI identifies patients at low risk for death or myocardial infarction, who infrequently require invasive coronary angiography.
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Affiliation(s)
- Nicole E Worden
- Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, USA.
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18
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Gada H, Moses JW. Adjudicating coronary revascularization: Appropriate Use Criteria are flawed and have been misapplied. Interv Cardiol 2015. [DOI: 10.2217/ica.14.63] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Kim LK, Feldman DN, Swaminathan RV, Minutello RM, Chanin J, Yang DC, Lee MK, Charitakis K, Shah A, Kaple RK, Bergman G, Singh H, Wong SC. Rate of percutaneous coronary intervention for the management of acute coronary syndromes and stable coronary artery disease in the United States (2007 to 2011). Am J Cardiol 2014; 114:1003-10. [PMID: 25118124 DOI: 10.1016/j.amjcard.2014.07.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 07/02/2014] [Accepted: 07/02/2014] [Indexed: 11/29/2022]
Abstract
Although the benefit of percutaneous coronary interventions (PCIs) for patients presenting with acute coronary syndromes (ACS) has been established in numerous studies, the role of PCI in stable coronary artery disease (CAD) remains controversial. With the publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluations trial and the appropriate use criteria for coronary artery revascularization, we sought to examine the impact of these treatment strategies and guidelines on the current practice of PCI in United States. We conducted a serial cross-sectional study with time trends of patients undergoing PCI for ACS and stable CAD from 2007 to 2011. The annual rate of all PCI decreased by 27.7% from 10,785 procedures per million adults per year in 2007 to 2008 to 7,801 procedures per million adults per year in 2010 to 2011 (p=0.03). Although there was no statistically significant decrease in the PCI utilization for ACS from 2007 to 2011, PCI utilization for stable CAD decreased by 51.7% (from 2,056 procedures per million adults per year in 2008 to 992 procedures per million adults per year in 2011, p=0.02). Hospitals with a higher volume of PCI experienced a more significant decrease. Decrease in PCI utilization for stable CAD was statistically significant for patients with Medicare and private insurance/health maintenance organization (44.5%, p=0.03 and 59.5%, p=0.007, respectively). In conclusion, the rate of PCI decreased substantially starting from 2009 in the United States. Most of the decrease was attributed to the reduction in PCI utilization for stable CAD.
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Affiliation(s)
- Luke K Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York.
| | - Dmitriy N Feldman
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Rajesh V Swaminathan
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Robert M Minutello
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Jake Chanin
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - David C Yang
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Min Kyeong Lee
- Department of Developmental Biology, Harvard School of Dental Medicine, Boston, Massachusetts
| | - Konstantinos Charitakis
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Ashish Shah
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Ryan K Kaple
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Geoffrey Bergman
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Harsimran Singh
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - S Chiu Wong
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
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