Geographic variations in percutaneous coronary interventions and coronary artery bypass graft surgery among Tennessee
Barbara J Kilbourne1, Robert S Levine, Warren Lambert
1Department of Family, Meharry Medical College, Nashville, TN, USA. bkilbourne@mmc.edu
Insights
Geographic location did not significantly impact guideline-based treatment for ST-elevation myocardial infarction (STEMI) patients, except for micropolitan residents. Policy changes could improve access to percutaneous primary coronary intervention (PPCI) and coronary artery bypass graft (CABG) for all.
Area of Science:
- Cardiology
- Health Services Research
- Rural Health
Background:
- ST-elevation myocardial infarction (STEMI) requires prompt reperfusion according to guidelines.
- Geographic variations in treatment access for STEMI are not well understood.
Purpose of the Study:
- To examine geographic disparities in guideline-based STEMI treatment (PPCI and CABG) across metropolitan, micropolitan, and non-micropolitan rural areas.
- To identify factors influencing the receipt of optimal STEMI care.
Main Methods:
- Analysis of 18,775 Tennessee Medicare beneficiaries with STEMI (1996-2002) using ICD-9 codes.
- Logistic regression models assessed treatment accord with guidelines based on county residence, hospital volume, race, gender, and age.
Main Results:
- Micropolitan residents had the lowest rates of percutaneous primary coronary intervention (PPCI) at 18.8%, compared to metropolitan (28.1%) and non-micropolitan rural (24.2%) residents.
- Coronary artery bypass graft (CABG) showed similar lower utilization patterns.
- High-volume PPCI centers mediated the likelihood of receiving PPCI based on location.
Conclusions:
- Access to optimal STEMI treatment options is not solely dependent on metropolitan residence.
- Centralizing emergency cardiac care could improve outcomes for micropolitan residents, aligning with "best practice" standards.
Objectives:
Coronary heart disease often presents with ST segment elevation acute myocardial infarction (STEMI). The American College of Cardiology/American Heart Association guidelines stress prompt reperfusion for STEMI. Examining geographic variations in treatment with PPCI (percutaneous primary coronary intervention) and CABG (coronary artery bypass graft) among metropolitan, micropolitan and non-micropolitan rural residents provides a descriptive basis for generating hypotheses concerning place and receipt of guidelines-based treatment.
Methods:
Using ICD-9 codes for STEMI and excluding beneficiaries with pre-existing MI in claims data, yielded a subset of 18,775 Tennessee Medicare beneficiaries experiencing STEMI from 1996 to 2002. The outcome variable is type of treatment, i.e., in accord (PPCI or CABG present) or not in accord (PPCI or CABG absent) with guidelines. Independent variables include type county residence, hospital volume, race, gender, and age. Analyses include cross-tabulation and logistic regression, estimating separate models by age and type of MI.
Results:
Micropolitan residents with STEMI have the lowest rates for PPCI (18.8%) versus 28.1% percent for metropolitan and 24.2% for non-micropolitan rural residents. CABG follows similar patterns at lower overall rates. Treatment at a heart center with high volume PPCI mediated the relationship between the likelihood of PPCI and place.
Conclusion:
The correspondence between metropolitan and rural utilization suggests that access to a full range of treatment options and likelihood of "best practice" care is not dependent on metropolitan residence. This presents the possibility that with some policy changes, e.g., centralization of emergency heart care, the same may ultimately be true for micropolitan residents.
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