Coronary Revascularization Trends in the United States, 2001-2008

Department of Veterans Affairs' Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 05/2011; 305(17):1769-76. DOI: 10.1001/jama.2011.551
Source: PubMed


Coronary revascularization is among the most common hospital-based major interventional procedures performed in the United States. It is uncertain how new revascularization technologies, new clinical evidence from trials, and updated clinical guidelines have influenced the volume and distribution of coronary revascularizations over the past decade.
To examine national time trends in the rates and types of coronary revascularizations.
A serial cross-sectional study with time trends of patients undergoing coronary artery bypass graft (CABG) surgery or percutaneous coronary interventions (PCIs) between 2001 and 2008 at US hospitals in the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, which reports inpatient coronary revascularizations. These data were supplemented by Medicare outpatient hospital claims.
Annual procedure rates of coronary revascularizations, CABG surgery, and PCI.
A 15% decrease (P < .001) in the annual rate of coronary revascularizations was observed from 2001-2002 to 2007-2008. The annual CABG surgery rate decreased steadily from 1742 (95% confidence interval [CI], 1663-1825) CABG surgeries per million adults per year in 2001-2002 to 1081 (95% CI, 1032-1133) CABG surgeries per million adults per year in 2007-2008 (P < .001), but PCI rates did not significantly change (3827 [95% CI, 3578-4092] PCI per million adults per year in 2001-2002 vs 3667 [95% CI, 3429-3922] PCI per million adults per year in 2007-2008, P = .74). Between 2001 and 2008, the number of hospitals in the Nationwide Inpatient Sample providing CABG surgery increased by 12% (212 in 2001 vs 241 in 2008, P = .03), and the number of PCI hospitals increased by 26% (246 in 2001 vs 331 in 2008, P < .001). The median CABG surgery caseload per hospital decreased by 28% (median [interquartile range], 253 [161-458] in 2001 vs 183 [98-292] in 2008; P < .001) and the number of CABG surgery hospitals providing fewer than 100 CABG surgeries per year increased from 23 (11%) in 2001 to 62 (26%) in 2008 (P < .001).
In US hospitals between 2001 and 2008, a substantial decrease in CABG surgery utilization rates was observed, but PCI utilization rates remained unchanged.

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    • "Coronary artery bypass grafting (CABG) remains the gold standard for the elective treatment of patients with complex and threevessel coronary artery disease [1]. Nonetheless, percutaneous coronary intervention (PCI) rates have increased over the past years, while CABG rates are declining despite better survival rates after CABG than after PCI in these patients [2] [3]. "
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    ABSTRACT: Objectives: Coronary artery bypass grafting is the gold standard for the treatment of patients with multiple-vessel coronary artery disease. The long-term outcome can be improved using arterial grafts. We analysed the initial series of patients who underwent total arterial revascularization at our institute using left internal thoracic artery (LITA) and radial artery (RA) composite T-grafts and had a follow-up of >10 years. Methods: We included all patients who received an isolated, non-emergent total arterial revascularization using LITA-RA T-grafts between September 1996 and August 2001 in our institution. We performed a follow-up of 138 patients (104 male, 60 ± 9 years old). Results: Early outcome was excellent. The 30-day mortality, reoperation, neurological complication and myocardial ischaemia rate was 1% (n = 2), 5% (n = 7), 2% (n = 3) and 2% (n = 3), respectively. Mean follow-up was 11 ± 3 years. Long-term survival was 79% (n = 86). There were seven cardiac deaths during follow-up. Freedom from major cardiovascular events for 1, 5 and 10 years was 97, 91 and 84%, respectively. A total of 95 coronary angiographies were performed 4.6 ± 4.1 years postoperatively. In total, 453 anastomoses using the composite graft (LITA-RA as T-graft) were performed. During follow-up, 35 anastomoses were occluded (30 RA anastomoses and 5 LITA anastomoses), leading to an occlusion rate of 7.7% during follow-up. Percutaneous coronary intervention was performed in 18 cases and coronary reoperation in two cases during follow-up. Quality-of-life assessment by Minnesota Living with Heart Failure Questionnaire revealed excellent results. Conclusions: Total arterial revascularization using composite LITA-RA T-grafts leads to excellent long-term results after >10 years.
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    • "Such Improvements in management including increased use of evidence-based therapies may have contributed to the decline in hospital stay shown in this study. Throughout the study period, the rate of CABG remained stable at around 2%, a finding consistent with a recent report in the other countries like USA [46]. "
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    • "Coronary stenting is widely utilized for the treatment of obstructive atherosclerotic coronary disease in the US [20]. Despite the widespread use of drug-eluting stents restenosis remains a pervasive problem occurring anywhere from 3–20% of patients with drug-eluting stent [21], depending on stent and patient characteristics. "
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