The consequences of under-use of coronary revascularization; results of a cohort study in Northern Italy

Area of Science:

• Cardiology
• Health Services Research
• Outcomes Research

Background:

• Coronary revascularization procedures, including coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA), are standard treatments for significant coronary artery disease.
• Assessing the impact of under-utilization of these procedures on patient outcomes is essential for quality improvement initiatives.

Purpose of the Study:

• To evaluate the association between the under-use of indicated coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) and patient mortality.
• To identify potential quality of care issues related to the under-utilization of revascularization procedures.

Main Methods:

• A prospective observational study followed 1258 patients eligible for CABG or PTCA after an index angiogram.
• Data on patient characteristics, procedures performed, and vital status were collected from multiple sources.
• Mortality was assessed at a minimum of 9 months follow-up, with unadjusted and adjusted analyses.

Main Results:

• Patients who underwent CABG or PTCA (n=863) had significantly lower mortality rates (4.8%) compared to those who did not (n=350, 10.6%; P=0.001).
• This finding remained significant after adjusting for risk factors and in survival analysis (adjusted OR=0.48, adjusted HR=0.31).

Conclusions:

• Failure to perform indicated revascularization procedures is associated with increased patient mortality, highlighting a potential quality of care problem.
• Limited healthcare capacity, such as waiting lists, may be a primary driver of this under-use.
• The study supports the validity of the RAND method for assessing the impact of under-use in coronary revascularization.