Influence of the Angioplasty Revascularization Investigation National Heart, Lung, and Blood Institute Diabetic...

Area of Science:

• Cardiology
• Diabetology
• Health Services Research

Background:

• The Bypass Angioplasty Revascularization Investigation (BARI) trial in 1995 indicated a survival benefit for diabetic patients undergoing surgical revascularization compared to balloon angioplasty.
• This finding led to a National Heart Lung and Blood Institute (NHLBI) Clinical Alert, but its impact on clinical practice was not well understood.

Purpose of the Study:

• To investigate the influence of the BARI trial findings and the subsequent NHLBI Clinical Alert on the practice patterns of coronary revascularization in diabetic patients with multivessel coronary artery disease.

Main Methods:

• Analysis of data from 9,619 patients with diabetes and multivessel coronary artery disease who underwent elective coronary revascularization between 1994 and 1997 across 13 National Cardiovascular Network centers.
• Assessment of changes in percutaneous revascularization rates before and after the Clinical Alert and examination of practice variability among hospitals.

Main Results:

• The NHLBI Clinical Alert did not significantly impact the proportion of diabetic patients receiving percutaneous revascularization (28.6% before vs. 26.8% after; P=0.06).
• Significant variability in percutaneous revascularization rates was observed across hospitals, ranging more than 13-fold (4.3% to 56.6%), even after adjusting for clinical factors and the BARI alert.
• Over 50% of surveyed clinicians felt the Clinical Alert had limited or no impact on their personal or institutional care patterns, despite high awareness (91%) and perceived validity (76%).

Conclusions:

• There is a lack of consensus on the optimal revascularization strategy for diabetic patients with multivessel coronary artery disease.
• A major clinical trial and subsequent alert failed to measurably influence practice variability in treating these patients.