A Falling Trend in U.S. Coronary Revascularization Procedures

Published in Circulation 2015 Jan 27; 131:362

Authors: Culler SD et al.

Published in Circulation 2015 Jan 27; 131:362

Findings from an analysis of two national Medicare databases

To determine recent trends in coronary revascularization among Medicare beneficiaries, researchers analyzed two national administrative databases. The data covered inpatient and outpatient percutaneous coronary interventions (PCIs) and coronary artery bypass grafting (CABG) procedures (N=2,768,007 patient records).

Between 2008 and 2012, the rate of revascularization procedures declined from 12.4/1000 to 10.3/1000 Medicare beneficiaries and fell ~4% per year in the last 2 years. CABG and valve surgery admissions remained constant or slightly increased. However, the fall in CABG rates was greater than the fall in PCI rates such that the PCI share of all revascularization procedures increased from ~75% to ~77%. The proportion of PCI recipients who were outpatients or who stayed overnight for observation with outpatient status increased from 14% to 27% over the study period. Overall mortality rates remained relatively constant for both PCI (range, 1.7%–1.9%) and CABG (range, 2.3%–2.6%). For both forms of revascularization, mortality was highest among patients with ST-segment elevation myocardial infarction.

Owing to the fall in procedures combined with growth in the number of programs, median volumes of PCI and CABG declined by 5 PCIs and 14 CABGs per facility. As a percentage of facilities performing PCI, those annually performing >500 PCIs fell from 15% to 11%; similarly, the percentage of facilities annually performing >250 CABG surgeries fell from 10% to 6%.

Comment
This study provides a fascinating look at the trends in coronary revascularization for Medicare recipients. The findings demonstrate that overall use is declining, slightly more so for CABG than PCI; more patients are getting outpatient PCI; and overall mortality is relatively constant. The trend toward fewer high-volume sites is concerning, and further analysis is necessary to determine whether this trend affects outcomes.