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Examining Coronary Revascularization Practice Patterns for Diabetics: Perceived Barriers, Facilitators, and
Kimberly J Miller1, Julie E Park2, Krishnan Ramanathan3
1British Columbia Centre for Improved Cardiovascular Health, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
Insights
Coronary artery bypass grafting (CABG) use increased after the FREEDOM trial for diabetes patients with multivessel disease in British Columbia. Practice changes varied, influenced by evidence, healthcare provider, patient, and system factors.
Area of Science:
- Cardiology
- Health Services Research
Background:
- The FREEDOM trial demonstrated coronary artery bypass grafting (CABG) superiority over percutaneous coronary intervention (PCI) for patients with diabetes mellitus (DM) and multivessel coronary artery disease (MV-CAD).
- Implementation of these findings into clinical practice remains a key challenge.
Purpose of the Study:
- To examine changes in practice patterns regarding CABG versus PCI for DM and MV-CAD patients in British Columbia (BC) following the FREEDOM trial publication.
- To identify perceived barriers and facilitators influencing the adoption of evidence-based practice.
Main Methods:
- Analysis of PCI:CABG ratios from a population-based cardiac procedures database in BC (2007-2014).
- Surveys administered to 57 healthcare providers (HCPs) across 5 tertiary cardiac centers in BC (2016-2017) to assess barriers and facilitators.
Main Results:
- The overall PCI:CABG ratio significantly decreased from 1.59 before the FREEDOM trial to 0.88 after publication (P < 0.01).
- Significant declines were observed in 3 of 4 centers, with one showing no significant change.
- Barriers included evidence applicability, HCP awareness, patient preferences, and systemic issues; facilitators included guidelines, education, shared decision-making, and team-based care.
Conclusions:
- Following the FREEDOM trial, CABG utilization increased among DM and MV-CAD patients in BC, but practice patterns varied by center.
- Multilevel barriers and facilitators significantly influenced these practice variations.
- Future knowledge translation strategies must be multifaceted and tailored to address identified determinants for effective evidence implementation.
Background:
The FREEDOM trial provided robust evidence that coronary artery bypass grafting (CABG) was superior to percutaneous coronary intervention (PCI) for coronary revascularization in patients with diabetes mellitus (DM) and multivessel coronary artery disease (MV-CAD). The present study examined practice pattern changes and perceived barriers and facilitators to implementing FREEDOM trial evidence in British Columbia (BC).
Methods:
Using a population-based database of cardiac procedures in BC, PCI:CABG ratios from 2007-2014 were compared before and after publication of the FREEDOM trial in the 4 tertiary cardiac centres that provided both CABG and PCI. Surveys of barriers and facilitators to implementation of evidence in practice were completed by 57 health care providers (HCPs) attending educational outreach sessions conducted in 2016-17 at 5 tertiary cardiac centres in BC.
Results:
The overall PCI:CABG ratio declined from 1.59 (95% confidence interval [CI] 1.48-1.70, range 1.16-1.86) before publication to 0.88 (95% CI 0.75-1.01, range 0.56-0.82) after publication (P < 0.01). This decline from before to after publication was significant in 3 centres, but not in the fourth centre (from 1.62 to 1.49; P = 0.61). Barriers were identified at the levels of evidence (applicability, credibility), HCP (awareness/knowledge, practice behaviours), patient (knowledge/misconceptions, preferences), and systems (siloing of care, financial disincentives, resource limitations, geography). Facilitators were additional studies/guidelines, education/dissemination, shared decision making, a heart team approach, changes to remuneration models, and increased resources.
Conclusions:
Following publication of the FREEDOM trial, the proportion of patients with DM and MV-CAD undergoing CABG increased in BC; however, practice patterns varied across cardiac centres. HCPs attributed these practice variations to multilevel barriers and facilitators. Future knowledge translation strategies should be multifaceted and tailored to identified determinants.
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