Use Of Coronary Revascularization Research Articles

National Trends and Outcomes of Acute Myocardial Infarction After Transcatheter Aortic Valve Replacement

BackgroundPrior studies have reported decreased use of an invasive approach for acute myocardial infarction (AMI) in patients undergoing transcatheter aortic valve replacement (TAVR). ObjectivesThe aim of this study was to determine whether prior TAVR affects the use of subsequent coronary revascularization and outcomes of AMI in a contemporary national data set. MethodsConsecutive TAVR patients from 2016 to 2022 were identified from the U.S. Vizient Clinical Data Base who were hospitalized after the index TAVR hospitalization with ST-segment elevation myocardial infarction (STEMI) or non–ST-segment elevation myocardial infarction (NSTEMI). Patients with STEMI or NSTEMI with or without prior TAVR from the same time period were compared for the use of coronary angiography, revascularization, and in-hospital outcomes. Propensity score matching was used to account for imbalances in patient characteristics. ResultsAmong 206,229 patients who underwent TAVR, the incidence of STEMI was 25 events per 100,000 person-years of follow-up, and that of NSTEMI was 229 events per 100,000 person-years. After propensity matching, the use of coronary revascularization was similar in the prior TAVR and no TAVR cohorts in both the STEMI (65.3% vs 63.9%; P = 0.81) and NSTEMI (41.4% vs 41.7%; P = 0.88) subgroups. Compared with patients without prior TAVR, in-hospital mortality was higher in the prior TAVR cohort in patients with STEMI (27.1% vs 16.7%; P = 0.03) and lower in those with NSTEMI (5.8% vs 8.2%; P = 0.02). ConclusionsIn this large, national retrospective study, AMI events after TAVR were infrequent. There were no differences in the use of coronary revascularization for STEMI or NSTEMI in TAVR patients compared with the non-TAVR population. In-hospital mortality for STEMI is higher in TAVR patients compared with those without prior TAVR.

Has the Expansion of Health Insurance Coverage via the Implementation of the Affordable Care Act Influenced Inequities in Coronary Revascularization in New York City?

In 2014, New York City implemented the Affordable Care Act (ACA) leading to insurance coverage gains intended to reduce inequities in healthcare services use. The paper documents inequalities in coronary revascularization procedures (percutaneous coronary intervention and coronary artery bypass grafting) usage by race/ethnicity, gender, insurance type, and income before and after the implementation of the ACA. We used data from the Healthcare Cost and Utilization Project to identify NYC patients hospitalized with the diagnosis of coronary artery disease (CAD) and/or congestive heart failure (CHF) in 2011-2013 (pre-ACA) and 2014-2017 (post-ACA). Next, we calculated age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization. Logistic regression models were used to identify the variables associated with receiving a coronary revascularization in each period. Age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization in patients 45-64years of age and 65years of age and older declined in the post-ACA period. Disparities by gender, race/ethnicity, insurance type, and income in the use of coronary revascularization persist in the post-ACA period. Although this health care reform law led to the narrowing of inequities in the use of coronary revascularization, disparities persist in NYC in the post-ACA period.

Estimating the economic impact of acute coronary syndrome in New Zealand over time (ANZACS-QI 64): a national registry-based cost burden study

ObjectivesTo estimate the changes in costs associated with acute coronary syndrome (ACS) admissions in New Zealand (NZ) public hospitals over a 12-year period.DesignA cost-burden study of ACS in NZ was...

Diagnostic features, management and prognosis of type 2 myocardial infarction compared to type 1 myocardial infarction: a systematic review and meta-analysis

ImportanceDistinguishing type 2 (T2MI) from type 1 myocardial infarction (T1MI) in clinical practice can be difficult, and the management and prognosis for T2MI remain uncertain.ObjectiveTo compare precipitating factors, risk factors,...

International Observational Analysis of Evolution and Outcomes of Chronic Stable Angina: The Multinational CLARIFY Study.

Although angina is common in patients with stable coronary artery disease, limited data are available on its prevalence, natural evolution, and outcomes in the era of effective cardiovascular drugs and widespread use of coronary revascularization. Using data from 32 691 patients with stable coronary artery disease from the prospective observational CLARIFY registry (Prospective Observational Longitudinal Registry of Patients with Stable Coronary Artery Disease), anginal status was mapped each year in patients without new coronary revascularization or new myocardial infarction. The use of medical interventions in the year preceding angina resolution was explored. The effect of 1-year changes in angina status on 5-year outcomes was analyzed using multivariable analysis. Among 7212 (22.1%) patients who reported angina at baseline, angina disappeared (without coronary revascularization) in 39.6% at 1 year, with further annual decreases. In patients without angina at baseline, 2.0% to 4.8% developed angina each year. During 5-year follow-up, angina was controlled in 7773 patients, in whom resolution of angina was obtained with increased use of antianginal treatment in 11.1%, with coronary revascularization in 4.5%, and without any changes in medication or revascularization in 84.4%. Compared to patients without angina at baseline and 1 year, persistence of angina and occurrence of angina at 1 year with conservative management were each independently associated with higher rates of cardiovascular death or myocardial infarction (adjusted hazard ratio, 1.32 [95% CI, 1.12-1.55] for persistence of angina; adjusted hazard ratio, 1.37 [95% CI, 1.11-1.70] for occurrence of angina) at 5 years. Patients whose angina had resolved at 1 year with conservative management were not at higher risk of cardiovascular death or myocardial infarction than those who never experienced angina (adjusted hazard ratio, 0.97 [95% CI, 0.82-1.15]). Angina affects almost one-quarter of patients with stable coronary artery disease but resolves without events or coronary revascularization in most patients. Resolution of angina within 1 year with conservative management predicted outcomes similar to lack of angina, whereas persistence or occurrence was associated with worse outcomes. Because most patients with angina are likely to experience resolution of symptoms, and because there is no demonstrated outcome benefit to routine revascularization, this study emphasizes the value of conservative management of stable coronary artery disease. Registration: URL: https://www.isrctn.com; Unique identifier: ISRCTN43070564.

Derivation and validation of a scoring system to predict after discharge risk of cardiac events in patients with acute myocardial infarction undergoing percutaneous coronary revascularization

Abstract Background In the acute coronary syndromes (ACS) setting, despite the extensive use of coronary revascularization and P2Y12 inhibitors such as prasugrel and ticagrelor, with a more pronounced inhibitory effect on platelets than clopidogrel, the rate of death and recurrent myocardial infarction (MI) at 1 year is still high. In this clinical setting the development of a risk score which takes into account patient's and procedural characteristics could represent a useful tool to identify patients at high risk for ischaemic events at 1 year who could take advantage from more aggressive secondary prevention strategies. Purpose The aim of our study was to develop a risk score to predict 1-year probability of after discharge cardiac events (recurrent MI and cardiac death) in patients with acute MI treated with percutaneous coronary intervention (PCI). Methods We prospectively enrolled all consecutive patients hospitalized for acute MI between 2003 and 2017 treated with PCI with/without stent placement at our center. We excluded patients who died in-hospital or who experienced in-hospital recurrent MI and patients undergoing surgical revascularization by coronary artery bypass graft (CABG). The patients of the final study cohort were therefore randomly assigned to either a derivation sample (60%) or a validation sample (40%). Based on the multivariate analysis we developed a point system according to the “Framingham Risk Score” method. Results The final study cohort, represented by 4922 patients, was split in a derivation sample of 2972 patients and in a validation sample of 1950 patients: in both groups the median age was around 70 years; the male prevalence was 73%; 65% of patients were dagnosed with ST-segment elevation MI. The clinical prediction score underlined as risk factors for recurrent cardiac events older age, diabetes mellitus, peripheral arterial disease, prior MI, Killip class >2 at presentation, higher platelet count and creatinine values, lower left ventricular ejection fraction; radial access and the use of second generation drug eluting stents resulted to be protective. This model showed a good discrimination power in both the derivation and the validation samples with an area under the curve (AUC) of 0.75 and 0.71, respectively. The calibration showed a good concordance between predicted and observed events in both the derivation and the validation samples. Same results were observed in patients with/without ST-segment elevation MI and in gender subgroups. Conclusions The present study, conducted retrospectively on a large population of patients with acute MI treated with PCI enrolled prospectively, enabled us to derivate and validate a risk score of cardiac death and recurrent MI at 1 year which took into account both clinical and procedural characteristics and which demonstrated a good predictive performance. After-discharge events by risk subgroups Funding Acknowledgement Type of funding source: None

Assessing the association of appropriateness of coronary revascularization and 1-year clinical outcomes for patients with stable coronary artery disease in China.

Background:The Chinese appropriate use criteria (AUC) for coronary revascularization was released in 2016 to improve the use of coronary revascularization. This study aimed to evaluate the association between the appropriateness of coronary revascularization based on the Chinese AUC and 1-year outcomes in stable coronary artery disease (CAD) patients.Methods: We conducted a prospective, multi-center cohort study of stable CAD patients with coronary lesion stenosis ≥50%. After the classification of appropriateness based on Chinese AUC, patients were categorized into the coronary revascularization group or the medical therapy group based on treatment received. The primary outcome was a composite of death, myocardial infarction, stroke, repeated revascularization, and ischemic symptoms with hospital admission.Results:From August 2016 to August 2017, 6085 patients were consecutively enrolled. Coronary revascularization was associated with a lower adjusted hazard of 1-year major adverse cardiovascular and cerebrovascular events (MACCEs; hazard ratio [HR]: 0.62; 95% confidence interval [CI]: 0.45–0.86; P = 0.004) than medical therapy in patients with appropriate indications (n = 1617). No significant benefit in 1-year MACCEs was found after revascularization compared to after medical therapy in patients with uncertain indications (n = 2658, HR: 0.81; 95% CI: 0.52–1.25; P = 0.338) and inappropriate indications (n = 1810, HR: 0.80; 95% CI: 0.51–1.23; P = 0.308).Conclusions:In patients with appropriate indications according to Chinese AUC, coronary revascularization was associated with significantly lower risk of MACCEs at 1 year. No benefit was found in coronary revascularization in patients with inappropriate indications. Our findings provide evidence for using Chinese AUC to guide clinical decision-making.Clinical trial registration:NCT02880605. https://www.clinicaltrials.gov.

Variation in Management of Patients With Obstructive Coronary Artery Disease: Insights From the Veterans Affairs Clinical Assessment and Reporting Tool (VA CART) Program.

BackgroundLittle is known about facility‐level variation in the use of revascularization procedures for the management of stable obstructive coronary artery disease. Furthermore, it is unknown if variation in the use of coronary revascularization is associated with use of other cardiovascular procedures.Methods and ResultsWe evaluated all elective coronary angiograms performed in the Veterans Affairs system between September 1, 2007, and December 31, 2011, using the Clinical Assessment and Reporting Tool and identified patients with obstructive coronary artery disease. Patients were considered managed with revascularization if they received percutaneous coronary intervention (PCI) or coronary artery bypass grafting within 30 days of diagnosis. We calculated risk‐adjusted facility‐level rates of overall revascularization, PCI, and coronary artery bypass grafting. In addition, we determined the association between facility‐level rates of revascularization and post‐PCI stress testing. Among 15 650 patients at 51 Veterans Affairs sites who met inclusion criteria, the median rate of revascularization was 59.6% (interquartile range, 55.7%–66.7%). Across all facilities, risk‐adjusted rates of overall revascularization varied from 41.5% to 88.1%, rate of PCI varied from 23.2% to 80.6%, and rate of coronary artery bypass graftingvariedfrom 7.5% to 36.5%. Of 6179 patients who underwent elective PCI, the median rate of stress testing in the 2 years after PCI was 33.7% (interquartile range, 30.7%–47.1%). There was no evidence of correlation between facility‐level rate of revascularization and follow‐up stress testing.ConclusionsWithin the Veterans Affairs system, we observed large facility‐level variation in rates of revascularization for obstructive coronary artery disease, with variation driven primarily by PCI. There was no association between facility‐level use of revascularization and follow‐up stress testing, suggesting use rates are specific to a particular procedure and not a marker of overall facility‐level use.

Long-term clinical outcomes and predictors for survivors of out-of-hospital cardiac arrest

AimsImprovement in resuscitation efforts has translated to an increasing number of survivors after out-of-hospital cardiac arrest (OHCA). Our objectives were to assess the long-term outcomes and predictors of mortality for patients who survived OHCA. MethodsWe conducted a population-based cohort study linking the Toronto RescuNET cardiac arrest database with administrative databases in Ontario, Canada. We included patients with non-traumatic OHCA from December 1, 2005 to December 31, 2014. The primary outcomes were mortality at 1 year and 3 years. Cox proportional hazard models were constructed to evaluate the predictors of mortality. ResultsAmong the 28,611 OHCA patients who received treatment at the scene of arrest, 1591 patients survived to hospital discharge. During hospitalization, 36% received coronary revascularizations and 27% received an implantable cardioverter defibrillator. At one year after discharge, 12.6% of patients had died and 37.3% were readmitted. At 3 years, mortality rate was 20% and all-cause readmission rate was 54.1%. Older age and a history of cancer were associated with higher risk of 3-year mortality. Shockable rhythm at presentation (hazard ratio [HR] 0.62, 95% CI 0.45–0.85), use of coronary revascularization (HR 0.37, 95% CI 0.28–0.51) or implantable cardioverter defibrillator (HR 0.28, 95% CI 0.20–0.41) was associated with substantially lower 3-year mortality. Prior cardiac conditions and other arrest characteristics were not associated with long-term mortality. ConclusionsSurvivors of OHCA face significant morbidity and mortality after hospital discharge. Clinical trials are needed to evaluate the potential benefits of invasive cardiac procedures in OHCA survivors.

Disparities by Race, Ethnicity, and Sex in Treating Acute Coronary Syndromes

Disparities in the management of coronary artery disease were consistently documented in blacks and women in the 1980s and 1990s. Our objective was to determine if racial/ethnic and sex differences in the use of coronary revascularization persist in a more recent cohort. We examined all 20,604 Medicare beneficiaries admitted for acute coronary syndrome in 2001 from a random sample of 750,000 enrollees that was oversampled for black and Hispanic subjects to assess any cardiac revascularization. After controlling for demographics and comorbidities, black men and women (odds ratios [OR] 0.47, 0.40), Hispanic men and women (ORs 0.61, 0.52), and white women (OR 0.67) had lower rates of revascularization compared with white men. Lower revascularization rates persisted for white women (OR 0.67) and black men and women (OR 0.55 and 0.54), controlling for income status and geographic variation, but were no longer present in the Hispanic population. The mechanisms by which disparities operate may differ for Hispanic and black populations.

Trends in postacute myocardial infarction management and mortality in patients with diabetes. A population-based study from 1995 to 2001

To compare trends in coronary revascularization use and case fatality rate (CFR) following acute myocardial infarction in patients with and without diabetes. A retrospective study of 77,552 patients, 20 years of age or older (25% with diabetes), who were hospitalized for a first acute myocardial infarction in the province of Quebec between April 1995 and December 2001 was conducted. Administrative databases were used to identify patients and assess outcomes. Compared with patients without diabetes, patients with diabetes underwent more coronary artery bypass graft (CABG) surgeries (11.1% versus 8.3%; P<0.0001) but fewer percutaneous coronary interventions (17.1% versus 20.2%; P<0.0001). The use of percutaneous coronary intervention increased substantially over time in both populations, driven mainly by an increase during the index admission (20.6% versus 16.6% per year; P=0.1144 in patients with and without diabetes, respectively). The use of CABG during the index admission increased markedly among patients with diabetes compared with those without (10.3% versus 5.3% per year; P=0.0072); however, at one-year following discharge, CABG use remained stable in patients with diabetes and fell in those without (-0.7% versus -5.3% per year; P=0.2046). Concomitantly, patients with diabetes presented a similar decline in CFR compared with patients without diabetes. The decline was more pronounced during the index admission (-5.0% versus -4.1% per year; P=0.282) than at one-year following discharge (-2.5% versus -2.5% per year; P=0.629) in patients with and without diabetes, respectively. However, fatal outcome remained higher in patients with diabetes than without, with an adjusted RR of 1.21 (95% CI 1.18 to 1.24) at one-year follow-up. Overall, coronary revascularization use and CFR improved over time in patients with diabetes. Nevertheless, the mortality rate in patients with diabetes remains higher than in patients without diabetes, indicating that additional progress is required to improve the poorer prognosis in this population.

ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization

The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an appropriateness review of common clinical scenarios in which coronary revascularization is frequently considered. The clinical scenarios were developed to mimic common situations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. Approximately 180 clinical scenarios were developed by a writing committee and scored by a separate technical panel on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization was considered appropriate and likely to improve health outcomes or survival. Scores of 1 to 3 indicate revascularization was considered inappropriate and unlikely to improve health outcomes or survival. The mid range (4 to 6) indicates a clinical scenario for which the likelihood that coronary revascularization would improve health outcomes or survival was considered uncertain. For the majority of the clinical scenarios, the panel only considered the appropriateness of revascularization irrespective of whether this was accomplished by percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). In a select subgroup of clinical scenarios in which revascularization is generally considered appropriate, the appropriateness of PCI and CABG individually as the primary mode of revascularization was considered. In general, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia was viewed favorably. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy were viewed less favorably. It is anticipated that these results will have an impact on physician decision making and patient education regarding expected benefits from revascularization and will help guide future research.

ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization

The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an appropriateness review of common clinical scenarios in which coronary revascularization is frequently considered. The clinical scenarios were developed to mimic common situations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. Approximately 180 clinical scenarios were developed by a writing committee and scored by a separate technical panel on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization was considered appropriate and likely to improve health outcomes or survival. Scores of 1 to 3 indicate revascularization was considered inappropriate and unlikely to improve health outcomes or survival. The mid range (4 to 6) indicates a clinical scenario for which the likelihood that coronary revascularization would improve health outcomes or survival was considered uncertain. For the majority of the clinical scenarios, the panel only considered the appropriateness of revascularization irrespective of whether this was accomplished by percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). In a select subgroup of clinical scenarios in which revascularization is generally considered appropriate, the appropriateness of PCI and CABG individually as the primary mode of revascularization was considered. In general, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia was viewed favorably. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy were viewed less favorably. It is anticipated that these results will have an impact on physician decision making and patient education regarding expected benefits from revascularization and will help guide future research.

Elevated Body Mass Index and Use of Coronary Revascularization after Cardiac Catheterization

Background Obese persons suffer discrimination in society that may extend to health care use. We investigated whether overweight and obese patients are as likely to undergo coronary reperfusion or revascularization as patients of normal body weight. Methods Detailed clinical data were collected for an inception cohort of patients from Alberta, Canada, who underwent cardiac catheterization between April 2001 and March 2004. The patients' likelihood of receiving any revascularization, percutaneous coronary intervention, or coronary artery bypass graft surgery in the year after cardiac catheterization was examined on the basis of body mass index (BMI) grouping. Use of revascularization was examined separately for patients with high- and low-risk coronary disease. Results Of 27,460 patients who had BMI data recorded, 24% were of normal weight, 42% were overweight, and 35% were obese. Although overweight and obese patients were more likely to have percutaneous coronary intervention (adjusted hazard ratio [HR] = 1.07, 95% confidence interval [CI], 1.01-1.12 and HR 1.08, 95% CI, 1.01-1.13, respectively), obese patients (BMI > 30) were less likely to receive coronary artery bypass graft surgery (adjusted HR = 0.93, 95% CI, 0.87-1.00). This was primarily because of less use of coronary artery bypass graft surgery for the most obese patients (obesity class III) with low-risk coronary anatomy (adjusted HR = 0.61, 95% CI, 0.36-1.02). Conclusion The pattern of use of revascularization procedures after cardiac catheterization differs somewhat across BMI subgroups. These differences might be clinically appropriate, but they warrant further exploration.

Diagnostic-Therapeutic Cascade Revisited

Background— There is wide geographic variation in the use of coronary revascularization in the United States. Rates are closely related to rates of coronary angiography. We assessed the relationship between coronary angiography and coronary artery revascularization by procedure type (coronary artery bypass graft surgery or percutaneous coronary intervention). Methods and Results— Using Part B claims for a 20% sample of the Medicare population, we calculated population-based rates of testing and treatment by region, using events identified in Part B claims as the numerator and the total number of Medicare beneficiaries residing in the area as the denominator and adjusting for regional differences in demographic characteristics with the indirect method. Cardiac catheterization rates varied substantially across regions, from 16 to 77 per 1000 Medicare beneficiaries. The relationship between coronary angiography rates and total coronary revascularization rates was strong ( R 2 =0.84). However, there was only a modest association between coronary angiography rates and coronary artery bypass graft surgery rates ( R 2 =0.41) with the suggestion of a threshold effect. The association between coronary angiography rates and percutaneous coronary intervention rates was strong ( R 2 =0.78) and linear. Conclusions— The diagnostic-therapeutic cascade for coronary artery disease differs by therapeutic intervention. For coronary artery bypass graft surgery, the relationship is modest, and there appears to be a testing threshold beyond which additional tests do not result in additional surgeries. For percutaneous coronary intervention, the relationship is very tight, and no threshold appears to exist. Given the results of recent studies of medical versus invasive management of stable coronary disease, patients living in high-diagnostic-intensity regions may be getting more treatment than they want or need.

Patients with end-stage renal disease and acute myocardial infarction have poor short-term outcomes despite modern cardiac intensive care

Cardiovascular disease has a tremendous impact on patients with end-stage renal disease (ESRD). We sought to describe the outcomes of patients with ESRD and acute myocardial infarction (AMI). We analyzed consecutive AMI patients admitted to a single coronary care unit, according to the presence or absence of ESRD. Multivariate modeling was used to determine the independent relationship between ESRD and in-hospital mortality. Data were available for 2025 AMI patients. ESRD was present in 82 patients (4%). Coronary angiography and revascularization were used aggressively in patients with ESRD, although less than among patients without ESRD (78 vs. 91%, P<0.001; and 60 vs. 79%, P<0.001, respectively). Length of stay was longer among patients with ESRD (9.5 vs. 5.0 days, P<0.001). In-hospital death occurred in 23.2% of the patients with ESRD compared with 9.0% of patients without ESRD (P<0.001). On multivariate analysis, the presence of ESRD was independently associated with the risk of in-hospital death (odds ratio 2.6, 95% confidence intervals, 1.3-4.9, P=0.005), even after controlling for the use of revascularization. Patients with ESRD and AMI are at tremendous risk for short-term mortality despite the aggressive use of coronary revascularization and modern coronary intensive care.

Gender disparity in cardiac procedures and medication use for acute myocardial infarction

Determine if gender bias is present in contemporary management of acute myocardial infarction (AMI). Despite major advances in medicine, disparities in healthcare still persist. Previous studies on gender bias in the diagnosis and treatment of AMI are inconsistent and may not represent more contemporary practice. Data were collected from the Minnesota Heart Survey, a population-based study of patients presenting with AMI in 2001-02. In-hospital diagnostic and therapeutic approaches were compared between women and men using logistic regression models. We identified 1242 women and 1378 men with an AMI defined by either positive cardiac biomarkers or ST-elevation on electrocardiogram. There were no differences in the prescription of aspirin, beta-blockers, ACE inhibitors or angiotensin receptor blockers. Women were 46% less likely than men to undergo investigative coronary angiography [OR = 0.54 (0.45-0.64)]. After accounting for confounders, women remained less likely to be referred for angiography [OR = 0.73 (0.57-0.94)]. Revascularization rates, were similar between women and men [OR = 0.96 (0.72-1.28)]. However, women were more likely to undergo PCI [OR = 1.41 (1.07-1.86)] whereas men were more likely to have coronary artery bypass grafting (CABG) [OR = 0.57 (0.39-0.84)]. When severity of coronary artery disease (CAD) was incorporated into the model, gender no longer influenced the modality of coronary revascularization. There is no evidence of gender bias in the pharmacologic treatment of AMI. Evidence of gender bias persists in the referral of patients for coronary angiography but not in the subsequent use of coronary revascularization.

Opening of Specialty Cardiac Hospitals and Use of Coronary Revascularization in Medicare Beneficiaries

Opening of Specialty Cardiac Hospitals and Use of Coronary Revascularization in Medicare Beneficiaries

Differences in Mortality and Use of Revascularization in Black and White Patients With Acute MI Admitted to Hospitals With and Without Revascularization Services

Racial differences in the use of coronary revascularization after acute myocardial infarction (AMI) have been widely reported. However, few studies have examined patterns of care for AMI patients admitted to hospitals with and without revascularization services. To compare rates of hospital transfer, coronary revascularization, and mortality after AMI for black and white patients admitted to hospitals with and without revascularization services. Retrospective cohort study of 1,215,924 black and white Medicare beneficiaries aged 68 years and older, admitted with AMI between January 1, 2000, and June 30, 2005, to 4627 US hospitals with and without revascularization services. For patients admitted to nonrevascularization hospitals, transfer to another hospital with revascularization services; for all patients, risk-adjusted rates of 30-day coronary revascularization and 1-year mortality. Black patients admitted to hospitals without revascularization were less likely (25.2% vs 31.0%; P<.001) to be transferred. Black patients admitted to hospitals with or without revascularization services were less likely to undergo revascularization than white patients (34.3% vs 50.2% and 18.3% vs 25.9%; P<.001) and had higher 1-year mortality (35.3% vs 30.2% and 39.7% vs 37.6%; P<.001). After adjustment for sociodemographics, comorbidity, and illness severity, blacks remained less likely to be transferred (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.75-0.81; P<.001) and undergo revascularization (HR, 0.71; 95% CI, 0.69-0.74; P<.001; and HR, 0.68; 95% CI, 0.65-0.70; P<.001 in hospitals with and without revascularization, respectively). Risk-adjusted mortality was lower for blacks during the first 30 days after admission (HR, 0.91; 95% CI, 0.88-0.93; P<.001; and HR, 0.90; 95% CI, 0.87-0.92; P<.001 in hospitals with and without revascularization, respectively) but was higher (P<.001) thereafter. Black patients admitted to hospitals with and without coronary revascularization services are less likely to receive coronary revascularization. The higher long-term mortality of black patients may reflect the lower use of revascularization or other aspects of AMI care.

Physician-Owned Specialty Hospitals and Coronary Revascularization Utilization

THE EMERGENCE OF SPECIALTY HOSPITALS THAT FOcus on lucrative procedural aspects of medicine has generated a heated debate among policy makers that largely involves 4 issues: patient selection (ie, “cherry-picking” of healthier and wealthier patients by specialty hospitals); quality of care in specialty and general hospitals; impact of specialty hospitals on the financial health of general hospitals; and influence of specialty hospitals on utilization and health care costs. The debate intensified in 2003 with the passage of a temporary congressional moratorium (allowed to expire in 2005) on new specialty hospital construction. However, empirical data addressing the 4 issues remain limited. Consistent evidence suggests that specialty hospitals admit patients with lower acuity and fewer comorbidities than general hospitals. Studies assessing quality have found that riskadjusted rates of adverse outcomes in specialty hospitals are similar or somewhat lower (perhaps 10%-20%) compared with general hospitals. While anecdotal reports about the negative influence of specialty hospitals on the financial health of general hospitals abound, limited data suggest that, thus far, the impact has been small. In this issue of JAMA, Nallamothu and colleagues provide intriguing new data suggesting that increases in the use of coronary revascularization were 2.5 to 3 times higher in health care markets that experienced entry of a new physician-owned specialty hospital compared with markets without specialty hospitals, including those markets in which new revascularization programs were established at general hospitals. The differences reflected a much lower decline in use of coronary artery bypass graft surgery and a larger increase in use of percutaneous coronary intervention (PCI). The increase in PCI was particularly striking among patients without acute myocardial infarction, a group for whom PCI may provide less benefit, but that accounted for more than two thirds of all PCI procedures. One potential explanation for these findings is that utilization in markets with specialty cardiac hospitals reflects that astute investors chose to open specialty hospitals in markets that were already experiencing rapid growth in demand for revascularization. However, additional analyses conducted by the authors provided little support for this possibility. Alternatively, the growth in utilization in markets with new specialty hospitals may be directly attributable to procedures performed in the new specialty hospitals. Indeed, at the end of the observation period, in the study by Nallamothu et al, specialty hospitals had approximately twice the volume as new cardiac programs in general hospitals and accounted for more than a third of all revascularization procedures performed in their markets. The current study would seem to support the hypothesis that specialty hospitals directly drive utilization of coronary revascularization. However, immediately drawing such a conclusion requires careful consideration and caution, particularly given the lack of direct information in the current study about the clinical appropriateness of procedures. Although new specialty hospitals may directly increase utilization by performing procedures for patients who might receive only marginal benefit from having interventions, it is also possible that specialty hospitals indirectly increase utilization by drawing patients away from existing general hospitals through competition. In turn, existing revascularization programs may respond to losses in patient volume with their own efforts to generate new business, further fueling utilization. Even though it is not possible to dissect the fundamental drivers of utilization from the study by Nallamothu et al, or the influence of increased utilization on patient outcomes, the results need to be considered in light of 3 important issues currently confronting the US health care system. First, and perhaps most important, increasing evidence suggests a general lack of association between more aggressive management practices and greater health care expenditures and better patient outcomes at a population level. At the individualpatient level, the recently published Occluded Artery Trial (OAT) found that PCI performed more than 3 days following an acute myocardial infarction provided no benefits relative to medical therapy. Yet payment policies promoted by Medicare and other third-party payers have created large fi-