Determinants of variations in coronary revascularization practices

Tu, Jack V.; Ko, Dennis T.; Guo, Helen; Richards, Janice; Walton, Nancy; Natarajan, Madhu K.; Wijeysundera, Harindra C.; So, Derek; Latter, David A.; Feindel, Christopher M.; Kingsbury, Kori; Cohen, Éric A.

doi:10.1503/cmaj.111072

Cited by 84 publications

(57 citation statements)

References 23 publications

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“…The CCN Cardiac Registry is an ongoing prospective registry storing clinical information on all invasive cardiac procedures in Ontario and has been used extensively in clinical research 20, 21, 22, 23. The registry contains detailed demographic, comorbidity, and procedural details, including coronary anatomy, that have been validated against chart abstraction and core laboratory verification 24, 25. All data were accessed and analyzed at ICES in Toronto, Canada.…”

Section: Methodsmentioning

confidence: 99%

Comparison of Anatomic and Clinical Outcomes in Patients Undergoing Alternative Initial Noninvasive Testing Strategies for the Diagnosis of Stable Coronary Artery Disease

Roifman

Wijeysundera

Austin

et al. 2017

JAHA

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BackgroundThe optimal initial noninvasive diagnostic testing strategy for stable coronary artery disease (CAD) is unknown. Although American guidelines recommend an exercise stress test as the first‐line test, European guidelines suggest that stress imaging (myocardial perfusion imaging or stress echocardiography) or coronary computed tomography angiography may be preferable. Understanding the relationship between the initial strategy and downstream yield of obstructive CAD and major adverse cardiac events may provide insight as to the optimal strategy.Methods and ResultsWe conducted a population‐based retrospective cohort study of adults in Ontario, Canada, using health administrative and clinical data. The relationship between the initial testing strategy and obstructive CAD on invasive angiography was examined. Patients were then followed from their angiogram onward to determine whether they developed a composite end point of major adverse cardiac events. After adjusting for covariates, patients with initial myocardial perfusion imaging (odds ratio: 0.92; 95% confidence interval, 0.85, 1.00), coronary computed tomography angiography (odds ratio: 1.51; 95% confidence interval, 0.91, 2.49), or stress echo (odds ratio: 0.95; 95% confidence interval, 0.84, 1.08) did not a have significantly different yield of obstructive CAD compared with those with an initial exercise stress test. Furthermore, there was no significant difference in downstream major adverse cardiac events after invasive angiography among the 4 initial testing strategies after adjusting for clinically relevant covariates.ConclusionsOur study found no evidence to suggest significant differences in either yield of obstructive CAD or downstream major adverse cardiac events in patients undergoing an initial noninvasive testing strategy with stress or anatomical imaging compared with those undergoing an initial exercise stress test.

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Section: Methodsmentioning

confidence: 99%

Comparison of Anatomic and Clinical Outcomes in Patients Undergoing Alternative Initial Noninvasive Testing Strategies for the Diagnosis of Stable Coronary Artery Disease

Roifman

Wijeysundera

Austin

et al. 2017

JAHA

Self Cite

View full text Add to dashboard Cite

show abstract

“…9 This registry contains detailed demographic, clinical, and procedural data, the accuracy of which has been validated through selected chart audits and angiographic core laboratory validation. 10 Data from the CCN registry were linked to populationbased administrative databases containing information on all Ontario residents. These databases are available at the Institute for Clinical Evaluative Sciences and were linked using encrypted unique patient identifiers.…”

Section: Methodsmentioning

confidence: 99%

Predictors and Outcomes of Routine Versus Optimal Medical Therapy in Stable Coronary Heart Disease

Chun

Qiu

Austin

et al. 2015

The American Journal of Cardiology

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“…Limited prior work describing facility rates of PCI to CABG has also shown determinants of variation in coronary revascularization practices include patient preferences, comorbid conditions, procedural findings, opinion of the primary operator (cardiologist who performed the elective diagnostic angiogram), and hospital culture 17, 18, 19. With multiple factors driving revascularization decisions, community data show a 2‐fold variation in revascularization attributable primarily to patient factors and procedural findings 17…”

Section: Discussionmentioning

confidence: 99%

Variation in Management of Patients With Obstructive Coronary Artery Disease: Insights From the Veterans Affairs Clinical Assessment and Reporting Tool (VA CART) Program

Sandhu

Stanislawski

Grunwald

et al. 2017

JAHA

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BackgroundLittle is known about facility‐level variation in the use of revascularization procedures for the management of stable obstructive coronary artery disease. Furthermore, it is unknown if variation in the use of coronary revascularization is associated with use of other cardiovascular procedures.Methods and ResultsWe evaluated all elective coronary angiograms performed in the Veterans Affairs system between September 1, 2007, and December 31, 2011, using the Clinical Assessment and Reporting Tool and identified patients with obstructive coronary artery disease. Patients were considered managed with revascularization if they received percutaneous coronary intervention (PCI) or coronary artery bypass grafting within 30 days of diagnosis. We calculated risk‐adjusted facility‐level rates of overall revascularization, PCI, and coronary artery bypass grafting. In addition, we determined the association between facility‐level rates of revascularization and post‐PCI stress testing. Among 15 650 patients at 51 Veterans Affairs sites who met inclusion criteria, the median rate of revascularization was 59.6% (interquartile range, 55.7%–66.7%). Across all facilities, risk‐adjusted rates of overall revascularization varied from 41.5% to 88.1%, rate of PCI varied from 23.2% to 80.6%, and rate of coronary artery bypass graftingvariedfrom 7.5% to 36.5%. Of 6179 patients who underwent elective PCI, the median rate of stress testing in the 2 years after PCI was 33.7% (interquartile range, 30.7%–47.1%). There was no evidence of correlation between facility‐level rate of revascularization and follow‐up stress testing.ConclusionsWithin the Veterans Affairs system, we observed large facility‐level variation in rates of revascularization for obstructive coronary artery disease, with variation driven primarily by PCI. There was no association between facility‐level use of revascularization and follow‐up stress testing, suggesting use rates are specific to a particular procedure and not a marker of overall facility‐level use.

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Determinants of variations in coronary revascularization practices

Cited by 84 publications

References 23 publications

Comparison of Anatomic and Clinical Outcomes in Patients Undergoing Alternative Initial Noninvasive Testing Strategies for the Diagnosis of Stable Coronary Artery Disease

Comparison of Anatomic and Clinical Outcomes in Patients Undergoing Alternative Initial Noninvasive Testing Strategies for the Diagnosis of Stable Coronary Artery Disease

Predictors and Outcomes of Routine Versus Optimal Medical Therapy in Stable Coronary Heart Disease

Variation in Management of Patients With Obstructive Coronary Artery Disease: Insights From the Veterans Affairs Clinical Assessment and Reporting Tool (VA CART) Program

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