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ILL-ADVISED AND UNNEEDED STENT OPERATIONS FINALLY DECLINING – A SMALL VICTORY FOR PATIENTS OVER UNETHICAL MEDICAL PROFITEERS
EXTRACTED FROM MEDPAGE TODAY, MAY 2011
A marked decline in the rate of coronary artery bypass graft (CABG) surgery led the way to a 15% overall decline in coronary revascularization procedures from 2001 to 2008, a nationwide survey showed.
The annual rate of CABG declined by almost 40%, whereas the rate of percutaneous coronary intervention (PCI) held steady during the study period, as reported in the May 4 issue of JAMA.
"Our findings suggest the possibility that several thousand patients who underwent PCI in 2008 would have undergone CABG surgery had patterns of care not changed markedly between 2001 and 2008," Andrew J. Epstein, PhD, of the Philadelphia Veterans Affairs Medical Center, and co-authors wrote.
"Our data imply a sizable shift in cardiovascular clinical practice patterns away from surgical treatment toward percutaneous, catheter-based interventions."
Since the beginning of the 21st century, the technology, published evidence, and clinical guidelines for coronary revascularization have changed substantially. How the changes affected the overall volume of revascularization and the different types of interventions has not been studied extensively, Epstein and co-authors noted in their introduction.
To determine the impact of innovation and evolution of coronary revascularization, investigators looked at the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample for the years 2001 to 2008. The dataset contains patient-level discharge information from about 1,000 hospitals in 42 states.
Using standard procedure and diagnosis codes, the authors identified all coronary revascularization procedures, and then categorized them as CABG, PCI with stent deployment (further subdivided into drug-eluting and bare-metal categories), and angioplasty without the use of a stent.
The authors also identified outpatient PCI procedures from the Centers for Medicare and Medicaid Services claims data.
Overall, the rate of coronary revascularization procedures declined from 5,569 per one million adults during 2001 to 2002 to 4,748 per one million adults during 2007 to 2008 (P<0.001).
During the same time period, the CABG rate declined from 1,742 to 1,081 per one million adults (P<0.001). The rate declined in a linear manner to 1,457 per one million during 2003 to 2004 and to 1,261 per one million adults during 2005 to 2006.
The total rate of PCI procedures did not change significantly from 2001 to 2002 (3,827 per one million adults) and 2007 to 2008 (3,667 per one million).
However, the rate of PCI procedures involving bare-metal stents declined 3,326 per one million in the first two years of the study period to 1,167 during the last two years (P<0.001). In fact, the rate reached a nadir of 468 per one million during 2005 to 2006 before increasing by more than twofold during 2007 to 2008.
No data were available for use of drug-eluting stents during the first two years of the study period. The rate increased from 2,040 per one million during 2003 to 2004 to a high of 3,507 per one million in 2005 to 2006 (P=0.001) before declining to 2,383 per one million during 2007 to 2008 (P=0.003).
Use of angioplasty without stents declined from 501 per one million during 2001 to 2002 to 117 per one million in the last two years (P<0.001).
The number of hospitals offering CABG increased by 12% (241 versus 212) from 2001 to 2008 (P=0.03), and the number of hospitals offering PCI increased by 26% (331 versus 246, P<0.001).
The median CABG caseload declined by 28%, from 253 per hospital in 2001 to 183 in 2008 (P<0.001). At the same time, the number of hospitals performing fewer than 100 CABG surgeries annually increased substantially from 23 in 2001 to 62 in 2008 (P<0.001).
The authors had no definitive explanations for the decline in CABG rate.
"The decreasing CABG surgery rate during this period of stable evidence and guidelines implies either overuse of CABG surgery in 2001, which has been progressively corrected by better patient selection, or increasing underuse of CABG surgery between 2001 and 2008 because patients who would have been optimally treated with CABG surgery were instead treated with PCI," the authors wrote in the discussion of their findings.
Primary source: JAMA
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