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Atrial Fibrillation and Stent Selection (Bare Metal vs Drug Eluting) (from Medicare Claims)
Greg Dadekian1, Aaron V Kaplan1, Chiang-Hua Chang2
1Cardiovascular Medicine Section, Heart & Vascular Center, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.
Insights
Patients with atrial fibrillation (AF) are more likely to receive bare metal stents (BMS) than drug-eluting stents (DES). Stent choice varies significantly across academic medical centers, indicating a need for further research.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Services Research
Background:
- Bare metal stents (BMS) and drug-eluting stents (DES) are used for coronary artery disease, with choices influenced by bleed risk and antiplatelet therapy needs.
- Atrial fibrillation (AF) complicates stent selection due to frequent anticoagulation use.
- Understanding stent choice patterns in patients with AF is crucial for optimizing cardiovascular care.
Purpose of the Study:
- To examine bare metal stent (BMS) versus drug-eluting stent (DES) selection in elderly Medicare beneficiaries with and without atrial fibrillation (AF).
- To assess the variation in stent choice across academic medical centers (AMCs) in the United States.
- To explore how cardiologists manage complex stent selection decisions in patients with AF.
Main Methods:
- Utilized a 100% Medicare denominator file and claims data from 2008-2012.
- Identified patients over age 65 receiving inpatient coronary artery stents.
- Measured BMS and DES use in patients with and without AF, adjusting for demographic factors and assessing inter-AMC variation.
Main Results:
- A total of 898,788 stent episodes were analyzed.
- BMS use decreased from 2008-2012 for both AF (42% to 34%) and non-AF (32% to 23%) patients.
- Adjusted stent choice varied substantially across AMCs, particularly for patients with AF, indicating significant practice pattern differences.
Conclusions:
- Patients with AF were more likely to receive BMS compared to those without AF.
- Significant variation in stent selection across academic medical centers suggests a lack of consensus in managing patients with AF.
- Further studies on stent choice and outcomes in AF patients are needed to guide clinical decisions and improve patient care.
Abstract:
In treating coronary artery disease, many factors influence the choice of bare metal stent (BMS) or drug-eluting stent (DES), including bleed risk and suitability for prolonged dual antiplatelet therapy. Atrial fibrillation (AF) further complicates this choice, due to common use of anticoagulation. We examined stent selection in the United States by AF status and across academic medical centers (AMCs) to explore how cardiologists are managing this complex choice. Using a 100% Medicare denominator file and associated claims (2008 to 2012), we identified patients over age 65 receiving inpatient coronary artery stents. We measured BMS and DES use in patients with AF and in patients without AF and assessed variation in stent choice across AMCs, adjusting for differences in age, gender, and race. We identified 898,788 stent episodes among elderly Medicare beneficiaries. BMS, as a percentage of total inpatient stent episodes, decreased from 2008 to 2012, in patients with AF (42% to 34%) and in patients without AF (32% to 23%). Across AMCs, adjusted stent choice varied substantially, but more so for patients with AF (2008 to 2012 median BMS 44% to 39%, annual interquartile ratios range 1.8 to 2.3) than patients without AF (2008 to 2012 median BMS 33% to 25%, annual interquartile ratios range 2.0 to 1.8). In conclusion, among stent recipients, patients with AF are more likely to receive BMS than patients without AF but treatment varies across systems, suggesting a lack of consensus. Studies of stent choice and outcomes among patients with AF are needed to guide care decisions and optimize outcomes.
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