Patterns of stress testing and diagnostic catheterization after coronary stenting in 250 350 medicare beneficiaries
Daniel W Mudrick1, Bimal R Shah, Lisa A McCoy
1Duke University Medical Center, Durham, NC 27705, USA.
Insights
Older patients undergoing percutaneous coronary intervention (PCI) commonly received stress tests (ST) or coronary angiography (CA) afterward. Paradoxically, higher-risk patients were less likely to undergo post-PCI testing, with low revascularization yield from ST referrals.
Area of Science:
- Cardiology
- Health Services Research
Background:
- Utilization of noninvasive stress testing (ST) and invasive coronary angiography (CA) after percutaneous coronary intervention (PCI) in older adults is not well understood.
- Understanding post-PCI testing patterns is crucial for optimizing care in aging populations.
Purpose of the Study:
- To describe the patterns of ST and CA utilization after PCI in older patients.
- To identify factors associated with downstream testing after PCI.
- To evaluate the outcomes of different testing strategies.
Main Methods:
- Linked National Cardiovascular Data Registry CathPCI Registry data with Medicare claims for 250,350 patients undergoing PCI (2005-2007).
- Described subsequent testing (ST or CA) and outcomes over a median follow-up of 24 months.
- Analyzed clinical risk factors associated with decreased likelihood of downstream testing.
Main Results:
- 49% received ST first, 10% underwent CA first, and 41% had no further testing within 60 days to 24 months post-PCI.
- Higher baseline risk factors (older age, heart failure, diabetes, renal failure) were paradoxically associated with decreased likelihood of downstream testing.
- 15% of patients who had ST first proceeded to CA within 90 days, with 7% undergoing revascularization; CA-first patients had a 53% revascularization rate.
Conclusions:
- ST and invasive CA are frequently used in older patients post-PCI.
- Higher-risk patients were less likely to receive recommended post-PCI testing.
- The yield for revascularization following ST referral after PCI was low.
Background:
Patterns of noninvasive stress test (ST) and invasive coronary angiography (CA) utilization after percutaneous coronary intervention (PCI) are not well described in older populations.
Methods And Results:
We linked National Cardiovascular Data Registry CathPCI Registry data with longitudinal Medicare claims data for 250 350 patients undergoing PCI from 2005 to 2007 and described subsequent testing and outcomes. Between 60 days post-PCI and end of follow-up (median 24 months), 49% (n=122 894) received ST first, 10% (n=25 512) underwent invasive CA first, and 41% (n=101 944) had no testing. Several clinical risk factors at time of index PCI were associated with decreased likelihood of downstream testing (ST or CA, P<0.05 for all), including older age (hazard ratio [HR] 0.784 per 10-year increase), male sex (HR 0.946), heart failure (HR 0.925), diabetes mellitus (HR 0.954), smoking (HR 0.804), and renal failure (HR 0.880). Fifteen percent of patients with ST first proceeded to subsequent CA within 90 days of testing (n=18 472/122 894) [corrected]; of these, 48% (n=8831) underwent revascularization within 90 days, compared with 53% (n=13 316) of CA first patients (P<0.0001).
Conclusions:
In this descriptive analysis, ST and invasive CA were common in older patients after PCI. Paradoxically, patients with higher risk features at baseline were less likely to undergo post-PCI testing. The revascularization yield was low on patients referred for ST after PCI, with only 7% [corrected] undergoing revascularization within 90 days.
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