Changes in Geographic Variation in the Use of Percutaneous Coronary Intervention for Stable Ischemic Heart Disease After Publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial

Mohan, Arun; Fazel, Reza; Huang, Pei–Hsiu; Shen, Yu‐Chu; Howard, David H.

doi:10.1161/circoutcomes.113.000282

Cited by 21 publications

(11 citation statements)

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“…16,20,21 PCI use has increased significantly in China 12 but varies by region, partly because of inconsistent medical development. 22 Identifying the determinants of IHM and PCI use among AMI patients is likely to be important in developing targeted interventions to improve access to PCI and to reduce AMI mortality. 23 Previous studies, however, used data from a specific region or selected hospitals [24][25][26][27][28] or focused on patients with ST-segment-elevation myocardial infarction (STEMI).…”

mentioning

confidence: 99%

Geographic Variations in In‐Hospital Mortality and Use of Percutaneous Coronary Intervention Following Acute Myocardial Infarction in China: A Nationwide Cross‐Sectional Analysis

Chen

Shi

Xue

et al. 2018

JAHA

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BackgroundPrevalence of acute myocardial infarction (AMI) is increasing in China, and AMI has become a major cause of mortality; however, information is very limited about the nationwide geographic and hospital variation in in‐hospital mortality (IHM) and the use of percutaneous coronary intervention (PCI) after AMI.Methods and ResultsFrom the Nationwide Hospital Discharge Database of China, we identified 242 866 adult admissions with AMI in 2015 from 1055 tertiary hospitals. We used multivariable logistic regressions to analyze the associations between geographic or hospital characteristics with IHM or PCI use. The national IHM rate was 4.71% (95% confidence interval, 4.62–4.79%). There was a greater risk of mortality in the Northeast (odds ratio [OR]: 1.86), West (OR: 1.73), South (OR: 1.32), and North (OR: 1.14) regions than in the East region of China. Non–teaching hospitals (OR: 1.18) and tertiary level B hospitals (OR: 1.06) were associated with higher IHM rates. The national PCI use rate was 45.3% (95% confidence interval, 45.1–45.5%). Compared with the East region of China, PCI use was lower in the Northeast (OR: 0.50), West (OR: 0.64), North (OR: 0.84), and South (OR: 0.88) regions. Non–teaching hospitals (OR: 0.83) and tertiary level B hospitals (OR: 0.55) were also associated with lower usage rates. There was a significant negative correlation between IHM and PCI use (r=−0.955), and IHM rates for patients with and without PCI both differed by geographic regions.ConclusionsThere were significant differences in IHM and PCI use among China's tertiary hospitals, linked to both geographic and hospital characteristics. More targeted intervention at national and regional levels is needed to improve access to effective health technologies and, eventually, outcomes following AMI.

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confidence: 99%

Geographic Variations in In‐Hospital Mortality and Use of Percutaneous Coronary Intervention Following Acute Myocardial Infarction in China: A Nationwide Cross‐Sectional Analysis

Chen

Shi

Xue

et al. 2018

JAHA

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“…26 The recognition that PCI has not been shown to reduce cardiovascular events, together with the introduction of appropriateness criteria in patients with stable ischemic heart disease, has been associated with a 25% decline in the rate of PCI use for such patients in the United States between 2006 and 2010. 27–29 However, in 2010 there were still 500 000 PCI procedures performed in the United States, of which perhaps half were for stable disease. 29 …”

Section: Meta-analysesmentioning

confidence: 99%

Reexamining the Efficacy and Value of Percutaneous Coronary Intervention for Patients With Stable Ischemic Heart Disease

Weintraub

Boden

2016

JAMA Intern Med

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Percutaneous coronary intervention (PCI) continues to be performed frequently for patients with stable ischemic heart disease, despite uncertain efficacy. Individual randomized trial data and meta-analyses have not demonstrated that PCI in addition to optimal medical therapy reduces the incidence of death or myocardial infarction in patients with stable disease. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial did not show benefit for cardiovascular outcomes or mortality but did find a modest improvement in quality of life that did not persist at 3 years. Long-term follow-up from COURAGE (up to 15 years) found no differences in mortality, consistent with other published literature. How PCI could reduce longterm mortality or prevent myocardial infarction is not clear because sites of future plaque rupture leading to myocardial infarction are unpredictable and PCI can only treat localized anatomic segments of obstructive atherosclerosis. In addition, PCI is expensive, and the value to society of PCI for stable disease has not been demonstrated. The ISCHEMIA trial will assess the role of PCI for stable ischemic heart disease using newer technology and in patients with greater ischemic burden than in COURAGE. After nearly a decade, the COURAGE trial and other studies have given us pause to critically reexamine the role of PCI for patients with stable ischemic heart disease. Until further research can show that PCI can reduce cardiovascular events in these patients, a first-line strategy of optimal medical therapy is known to be safe, effective, and noninferior to PCI, and our practice should more closely follow this strategy.A wise man, therefore, proportions his beliefs to the evidence.

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“…However, only few studies have further examined the regional and hospital variations in the percentage of PCIs for nonacute indications [5, 9, 10]. …”

Section: Introductionmentioning

confidence: 99%

“…Mohan et al suggested that among hospital referral regions, the variations in the rate of PCIs performed for SIHD declined by 28% after the publication of the COURAGE study, but geographic variations remained higher for SIHD than for acute coronary syndrome [5]. Two studies have revealed that although the overall proportion of nonacute PCIs classified as inappropriate has declined, the hospital-level variations in inappropriate PCIs persist [9, 10].…”

Section: Introductionmentioning

confidence: 99%

Regional and hospital variations in the extent of decline in the proportion of percutaneous coronary interventions performed for nonacute indications – a nationwide population-based study

Liang

et al. 2017

BMC Cardiovasc Disord

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BackgroundThe volume and percentage of percutaneous coronary interventions (PCIs) performed for nonacute indications have declined in the United States since 2007. However, little is known if similar trends occurred in Taiwan.MethodsWe used data from Taiwan National Health Insurance inpatient claims to examine the regional and hospital variations in the extent of decline in the percentage of nonacute indication PCIs from 2007 to 2012.ResultsThe volume of total PCIs persistently increased from 29,032 in 2007 to 35,811 in 2010 and 37,426 in 2012. However, the volume of nonacute indication PCIs first increased from 7916 in 2007 to 9143 in 2009 and then decreased to 8666 in 2012. The percentage of nonacute indication PCIs steadily decreased from 27% in 2007 to 26% in 2009 and then to 23% in 2012, a − 15% change. The extent of decline was largest in the North region (from 27% to 21%, a − 22% change) and least in Kaopin region (from 20% to 18%, a − 13% change). Of the 71 hospitals studied, 14 did not show a decreasing trend. Five of the 14 hospitals even showed an increasing trend, with a percentage change >10% between 2007 and 2012. In 2012, 6 hospitals had a nonacute indication PCI percentage >35%.ConclusionsIn Taiwan, four-fifths of the hospitals showed a decline in the percentage of nonacute indication PCIs from 2007 to 2012. It is plausible that Taiwanese cardiologists would have been influenced by the recommendations of crucial US trials and guidelines.

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Changes in Geographic Variation in the Use of Percutaneous Coronary Intervention for Stable Ischemic Heart Disease After Publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial

Cited by 21 publications

References 50 publications

Geographic Variations in In‐Hospital Mortality and Use of Percutaneous Coronary Intervention Following Acute Myocardial Infarction in China: A Nationwide Cross‐Sectional Analysis

Geographic Variations in In‐Hospital Mortality and Use of Percutaneous Coronary Intervention Following Acute Myocardial Infarction in China: A Nationwide Cross‐Sectional Analysis

Reexamining the Efficacy and Value of Percutaneous Coronary Intervention for Patients With Stable Ischemic Heart Disease

Regional and hospital variations in the extent of decline in the proportion of percutaneous coronary interventions performed for nonacute indications – a nationwide population-based study

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