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Published on: May 14, 2013
Institutional volumes and coronary angioplasty outcomes before and after the introduction of stenting
C Maynard1, N R Every, M K Chapko
1Department of Veterans Affairs and Department of Health Services, University of Washington, USA.
Insights
Coronary stenting has not changed hospital mortality after percutaneous transluminal coronary angioplasty (PTCA). However, same-admission coronary artery bypass grafting (CABG) rates decreased and were lowest at high-volume stenting centers.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Health Services Research
Background:
- An increasing number of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) are receiving coronary stents.
- The impact of coronary stenting on patient outcomes and procedural trends requires evaluation.
Purpose of the Study:
- To assess the effect of coronary stenting introduction on hospital mortality and same-admission coronary artery bypass grafting (CABG).
- To determine if hospital procedure volume influences these outcomes.
Main Methods:
- Observational study utilizing California hospital claims data from 1993 and 1996.
- Analysis of 35,350 patients undergoing PTCA in 1993 and 43,040 in 1996, with 43% receiving stents in 1996.
- Categorization of hospitals based on annual stenting volumes (low, medium, high) and analysis of outcomes including hospital death and same-admission CABG.
Main Results:
- Hospital mortality rates after PTCA remained unchanged between 1993 and 1996.
- Rates of same-admission CABG significantly decreased in both acute myocardial infarction (AMI) and no-AMI patient groups.
- Same-admission CABG rates were significantly lower in high-volume stenting hospitals compared to low-volume centers.
Conclusions:
- The introduction and widespread use of coronary stenting have not significantly altered hospital mortality following PTCA.
- A notable decrease in same-admission CABG has occurred, with the lowest rates observed in hospitals performing a high volume of stenting procedures.
Context:
An increasing number of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) are receiving coronary stents.
Objectives:
To assess whether the introduction of coronary stenting has changed hospital mortality or same-admission coronary artery bypass grafting (CABG) and whether the hospital's procedure volume affects these outcomes.
Design:
Observational study using hospital claims.
Setting:
Nonfederal hospitals that performed PTCA in California in 1993 and 1996.
Patients:
35,350 patients who underwent PTCA in 1993 (before the introduction of stenting) and 43,040 patients who had PTCA in 1996 (43% of whom received stents).
Measurements:
Hospital stenting volumes for 1996 were divided into terciles; total PTCA procedures per year were categorized as low (< or = 200), medium (201 to 400), or high (> 400). Outcome variables included hospital death and coronary artery bypass grafting (CABG) performed during the same admission. Patients with a principal diagnosis of acute myocardial infarction (AMI) were analyzed separately from those without such a diagnosis.
Results:
From 1993 to 1996, the characteristics of patients undergoing PTCA did not change substantially. The use of same-admission CABG decreased by 13% (from 6.0% to 5.2%; P = 0.008) in the AMI group and by 30% (from 3.7% to 2.6%; P < 0.001) in the no-AMI group. Hospital mortality did not change significantly in either group. Procedure volume was not related to hospital mortality. However, rates of same-admission CABG were significantly lower at hospitals with high annual stenting volumes than at low-volume centers (1.3% vs. 2.3% among patients in the no-AMI group; P < 0.001).
Conclusions:
Hospital mortality rates after PTCA have not changed considerably since the introduction and diffusion of coronary stenting. However, rates of same-admission CABG have decreased in recent years and are lowest at hospitals with high procedure volumes.
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