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Variation in the use of cardiac procedures after acute myocardial infarction
E Guadagnoli1, P J Hauptman, J Z Ayanian
1Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
Insights
Geographic variations in cardiac procedures like angiography exist. Higher rates in Texas did not improve mortality or quality of life compared to New York, suggesting no benefit from increased use.
Area of Science:
- Cardiology
- Health Services Research
- Outcomes Research
Background:
- Significant geographic disparities exist in the utilization of coronary angiography and revascularization procedures.
- Variability in procedure rates may be influenced by patient case mix or treatment patterns for specific patient groups.
- Assessing the impact of these treatment patterns on patient outcomes is crucial.
Purpose of the Study:
- To investigate whether differences in patient case mix or treatment strategies explain geographic variations in coronary angiography and revascularization rates.
- To evaluate the consequences of differing procedural patterns on mortality and health-related quality of life.
Main Methods:
- A comparative study of Medicare patients aged 65-79 with acute myocardial infarctions in New York (low procedure use) and Texas (high procedure use) in 1990.
- Analysis of treatment patterns for clinically similar patient groups across the two states.
- Comparison of two-year mortality rates and health-related quality of life measures.
Main Results:
- Coronary angiography was performed more frequently in Texas (45%) than in New York (30%).
- Higher procedure rates in Texas were not associated with lower mortality or better quality of life; in fact, Texas patients reported more angina and functional limitations.
- Adjusted two-year mortality was lower in New York (hazard ratio, 0.87).
Conclusions:
- Physician preference for angiography in Texas was higher, particularly when clinical discretion allowed.
- Increased use of cardiac procedures in Texas did not confer advantages in mortality or health-related quality of life compared to the lower rates in New York.
Background:
There are large geographic differences in the frequency with which coronary angiography and revascularization are performed. We attempted to assess whether differences in case mix or in the treatment of specific groups of patients may explain this variability. We also assessed the consequences of various patterns of treatment.
Methods:
We studied patients covered by Medicare who were 65 to 79 years of age and were admitted to 478 hospitals with acute myocardial infarctions during 1990 in New York (1852 patients), where the rate of use of cardiac procedures is low, and in Texas (1837 patients), where the rate of use of such procedures is high. We compared the patterns of treatment of clinically similar groups of patients in the two states. We also compared mortality rates and measures of the health-related quality of life.
Results:
Coronary angiography was performed more often in Texas than in New York (45 percent vs. 30 percent, P < 0.001). The frequency of use in Texas was significantly higher than that in New York for all the clinical subgroups of patients analyzed except those at greatest risk for reinfarction. Over a two-year period, the adjusted likelihood of death was lower in New York than in Texas (hazard ratio, 0.87; 95 percent confidence interval, 0.78 to 0.98). Patients from Texas were 41 percent more likely to report angina (P = 0.002) and 62 percent more likely to say they could not perform activities requiring energy expenditure of 5 or more metabolic equivalents than patients from New York approximately two years after infarction (P < 0.001).
Conclusions:
Physicians in Texas were more likely to perform angiography than physicians in New York for patients whose conditions allowed more discretion in the use of cardiac procedures. On average, there appears to be no advantage with respect to mortality or health-related quality of life to performing the procedures at the higher rate used in Texas.