Sex and Race Differences in the Utilization and Outcomes of Coronary Artery Bypass Grafting Among Medicare Beneficiaries, 1999–2014

Abstract

BackgroundWith over a decade of directed efforts to reduce sex and racial differences in coronary artery bypass grafting (CABG) utilization, and post‐CABG outcomes, we sought to evaluate how the use of CABG and its outcomes have evolved in different sex and racial subgroups.Methods and ResultsUsing data on all fee‐for‐service Medicare beneficiaries undergoing CABG in the United States from 1999 to 2014, we examined differences by sex and race in calendar‐year trends for CABG utilization and post‐CABG outcomes (in‐hospital, 30‐day, and 1‐year mortality and 30‐day readmission). A total of 1 863 719 Medicare fee‐for‐service beneficiaries (33.6% women, 4.6% black) underwent CABG from 1999 to 2014, with a decrease from 611 to 245 CABG procedures per 100 000 person‐years. Men compared with women and whites compared with blacks had higher CABG utilization, with declines in all subgroups. Higher post‐CABG annual declines in mortality (95% confidence interval) were observed in women (in‐hospital, −2.70% [−2.97, −2.44]; 30‐day, −2.29% [−2.54, −2.04]; and 1‐year mortality, −1.67% [−1.88, −1.46]) and blacks (in‐hospital, −3.31% [−4.02, −2.60]; 30‐day, −2.80% [−3.49, −2.12]; and 1‐year mortality, −2.38% [−2.92, −1.84]), compared with men and whites, respectively. Mortality rates remained higher in women and blacks, but differences narrowed over time. Annual adjusted 30‐day readmission rates remained unchanged for all patient groups.ConclusionsWomen and black patients had persistently higher CABG mortality than men and white patients, respectively, despite greater declines over the time period. These findings indicate progress, but also the need for further progress.

Patient and hospital factors associated with 30-day readmissions after coronary artery bypass graft (CABG) surgery: a systematic review and meta-analysis

“…This might be due to the fact that year of publication does not always correlate with year of clinical practice, given some studies covered a large period of time. Two of the included studies [ 12 , 13 ] using national data for Medicare beneficiaries reported decreasing trends of readmission within 30 days following CABG over the period 1999–2014 while another study [ 14 ] reported that the readmission rates did not vary significantly in New York and California states over the period 2005–2011.…”

“…Identifying the underlying causes of readmission can highlight which care processes should be the focus of attention and effort, whereas examining the patient-level factors associated with readmission can help to identify patient groups to target for improved inpatient care and post-procedure follow-up. Because substantial between-hospital variation in post-CABG readmission rate has been reported previously [ 12 – 14 ] and policies on patient safety and quality of care are usually implemented at the hospital level, certain hospital characteristics may also need to be targeted. To date, no study has systematically collated the evidence regarding the causes of post-CABG readmissions and patient-level as well as hospital-level characteristics associated with such readmissions.…”

Association between Transesophageal Echocardiography and Clinical Outcomes after Coronary Artery Bypass Graft Surgery

“…6,7 Moreover, among Medicare beneficiaries aged $65 years, undergoing isolated CABG surgery has an even higher (3.2%-4.7%) mortality risk. 8,9 Transesophageal echocardiography (TEE) is an ultrasound-based cardiac imaging modality that may improve clinical outcomes after CABG surgery by permitting continuous interoperative hemodynamic monitoring, managing surgical complications related to cardiopulmonary bypass, [10][11][12][13][14][15][16][17][18] and facilitating surgical decision-making intraoperatively. 14,15,19 But it is unclear if TEE, a procedure that is not without risk, 20 improves postoperative outcomes after CABG surgery, because existing observational studies 14,15 are limited by an inability to account for the nonrandom selection of patients.…”

Coronary surgery in women: How can we improve outcomes

“…16,17 In 3 large contemporary reports (ranging from 1.8 to 3.8 million patients each), women comprised a lower percentage of overall CABG use and a higher operative mortality after CABG. 5,23,24 Using the National Inpatient Sample database, Mahowald and colleagues 24 demonstrated a consistently higher in-hospital mortality before and after propensity matching in women undergoing CABG after myocardial infarction, compared with men between 2003 and 2016 in 3.6 million patients (33% women). Also using the National Inpatient Sample, Mohamed and colleagues 24 found declining mortality in all patients (2.5 million, 28% women) over time (2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015) after CABG; however, mortality was persistently higher in women, even after adjustment for risk factors, and women had a 43% increased odds of mortality compared with men.…”

“…1,2 Women have had lower rates of CABG compared with men (13%-16% in the late 1970s 3,4 ) to 29% in 2014. 5 In addition, there was a greater relative decline in the use of CABG in women between 1999 until 2014 (66% decline in women vs 60% in men). 5 Thus, treatment decisions for women with coronary artery disease have been based on data that are limited and may not be applicable, appropriate, or optimal.Fortunately, to ensure that the National Institutes of Health (NIH) is funding the highest quality science, the NIH now requires that rigor and transparency be addressed in every grant application submitted.…”