Impact of Area Deprivation Index on Coronary Stent Utilization in a Medicare Nationwide Cohort

Area Deprivation Index (ADI) is a marker of neighborhood deprivation. This study investigates utilization of coronary bare-metal stent (BMS) and drug-eluting stent (DES) in Medicare patients across hospitals with varying ADI. Data were abstracted using Diagnosis-Related Group (DRG) codes 249 (BMS without major complications or comorbidities [MCC]), 246, and 247 (DES with and without MCC, respectively) from the 2011-2012 Medicare Provider Utilization and Payment Data Inpatient File, which was linked to American Hospital Association data (to determine bed size, location, ownership, teaching status), and ADI for each hospital zip code was obtained. Hospitals were divided into quintiles using ADI values: Quintile 1 (privileged) to Quintile 5 (deprived). Logistic regression was conducted to determine odds ratios (ORs) for DES utilization across ADI quintiles. There were 313,739 discharges with DRG codes 246 (52,839), 247 (203,928), and 249 (56,972). DES utilization was lower in the deprived quintile, irrespective of teaching status. It was lower in larger hospitals and hospitals with more annual stent discharges, urban locations and nongovernment not-for-profit institutes. Lower odds of DES utilization were found in Quintile 2 (OR-0.9, 95% confidence interval [CI] 0.87-0.93, P < 0.001), Quintile 3 (OR-0.89, 95% CI 0.86-0.92, P < 0.001), and Quintile 4 (OR-0.95, 95% CI 0.92-0.98, P = 0.001) versus Quintile 1 and there was no difference in utilization of DES in Quintile 5 (OR-1.01, 95% CI 0.98-1.04, P = 0.6) versus Quintile 1. Significant differences exist in DES utilization in a large, uniformly insured cohort based on neighborhood deprivation.