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Research Letter |

Population Trends in Rates of Coronary Revascularization FREE

Robert W. Yeh, MD, MSc1; Laura Mauri, MD, MSc2; Robert E. Wolf, MS3; Iyah K. Romm, BS4; Ann Lovett, RN, MA3; David Shahian, MD5; Sharon-Lise Normand, PhD3
[+] Author Affiliations
1Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston
2Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
3Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
4Health Policy Commission, Commonwealth of Massachusetts, Boston
5Department of Surgery and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston
JAMA Intern Med. 2015;175(3):454-456. doi:10.1001/jamainternmed.2014.7129.
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Published online

Improvements in prevention have led to declines in rates of myocardial infarction (MI).1 Simultaneously, evidence from randomized trials has confirmed the role of medical therapy as a first-line treatment for stable coronary disease.2 Together, these forces could lead to significant declines in population-wide rates of coronary revascularization. We examined recent temporal trends in population rates of coronary revascularization using comprehensive clinical data collected in Massachusetts.

Approval for the study was granted by the Massachusetts Department of Public Health review committee (RADAR). We conducted a retrospective dynamic cohort study of all Massachusetts residents undergoing coronary revascularization at nonfederal hospitals from April 2003 through September 2012. These residents included patients undergoing inpatient or outpatient percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) with and without concomitant valve or aortic surgery. We counted only the first procedure per year per patient. Procedures were classified as “urgent” if done in the setting of MI (within 21 days of MI for CABG) and were classified as “elective” if otherwise. Population denominators were obtained from the US census, stratified by sex and age.3 Direct methods for adjustment were applied using the 2012 population as standard.1 Cochran-Armitage testing was used to assess linear trend.

From April 2003 through September 2012, 171 702 coronary revascularization procedures (PCI, 76.9%; CABG, 23.1%) were included. The mean adult Massachusetts population was 5.2 million. The age- and sex-adjusted rate of coronary revascularization declined from 423 per 100 000 to 258 (P < .001) (Figure 1), a 39.0% decline during the study period. Rates of PCI declined from 318 to 200 per 100 000, while rates of CABG declined from 113 to 63 per 100 000 (P < .001 for both).

Place holder to copy figure label and caption
Figure 1.
Temporal Trends in Population-Wide Rates of Coronary Revascularization in Massachusetts, 2003-2012

Rates reflect the number of unique individuals undergoing revascularization in a given year, per 100 000 residents, and are adjusted for age and sex. CABG indicates coronary artery bypass graft surgery; and PCI, percutaneous coronary intervention.

Graphic Jump Location

Among PCIs, elective PCIs declined from 206 to 109 per 100 000 (P < .001), while urgent procedures declined from 119 to 100 per 100 000 (P < .001) (Figure 2). Elective CABG declined from 82 to 45 per 100 000, while urgent CABG declined from 31 to 18 per 100 000 (P < .001). Isolated CABG rates fell from 90 to 45 per 100 000 (P < .001), while combined CABG and aortic or mitral valve surgery did not change (10 per 100 000 in 2003 vs 10 per 100 000 in 2012).

Place holder to copy figure label and caption
Figure 2.
Temporal Trends in Rates of PCI and CABG, Stratified by Presentation With or Without MI

Rates reflect the number of unique individuals with and without MI undergoing PCI or CABG in a given year, per 100 000 residents, and are adjusted for age and sex. CABG indicates coronary artery bypass graft surgery; MI, myocardial infarction; and PCI, percutaneous coronary intervention.

Graphic Jump Location

We observed steep declines in population-wide rates of coronary revascularization in Massachusetts over the previous decade. For PCI, reductions in rates were greater in magnitude for elective procedures than for procedures done for MI, declining by nearly 50% between 2003 and 2012 for elective PCI compared with a 16.4% decline for urgent PCI over the same period.

The causes of the observed trends are likely multifactorial. Significant reductions in rates of MI have been observed in multiple populations, likely attributable to improved primary and secondary prevention.4,5 The publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial2 comparing PCI with initial medical therapy for stable angina was temporally associated with the steepest 1-year decline in elective PCI rates. Explicit attention to the appropriate use of PCI may also have contributed to more recent declines in PCI.6

This study has several limitations. We cannot know with certainty what has led to the observed trends, and our results may not generalize to other geographic locations. Also, we did not capture outcomes of patients who may have been considered for, but did not undergo, coronary revascularization and do not know if overall cardiovascular outcomes in these patients has changed.

In conclusion, we found that rates of coronary revascularization have declined by nearly 40% in Massachusetts since 2003, with the most rapid declines in elective PCI procedures and isolated CABGs. These data have broad implications for regional health policy, training and provider accreditation, hospital resource allocation, and patient outcomes.

Corresponding Author: Robert W. Yeh, MD, MSc, Cardiology Division, Massachusetts General Hospital, GRB 8-843, Boston, MA 02114 (ryeh@partners.org).

Published Online: January 5, 2015. doi:10.1001/jamainternmed.2014.7129.

Author Contributions: Dr Yeh had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Yeh, Mauri, Romm.

Acquisition, analysis, or interpretation of data: Yeh, Mauri, Wolf, Lovett, Normand.

Drafting of the manuscript: Yeh, Wolf.

Critical revision of the manuscript for important intellectual content: Yeh, Mauri, Wolf, Romm, Lovett, Normand.

Statistical analysis: Wolf, Normand.

Obtained funding: Normand.

Administrative, technical, or material support: Romm, Lovett, Normand.

Study supervision: Yeh.

Conflict of Interest Disclosures: Dr Yeh receives funding from the National Heart, Lung, and Blood Institute (grant 1K23HL118138), the Hassenfeld Scholars Program, and the Harvard Clinical Research Institute. Dr Mauri receives institutional research support from Abbott, Boston Scientific, Cordis, Medtronic, Eli Lilly, Daiichi Sankyo, Bristol Myers Squibb, and Sanofi, and has consulted for Cordis, Medtronic, Boston Scientific, and Biotronik. No other disclosures are reported.

Funding/Support: The work was supported, in part, by the Hassenfeld Scholars Program.

Role of the Funder/Sponsor: The Hassenfeld Scholars Program had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Treacy Silbaugh, BSc, Katya Zelevinksy, BA, and Matthew Cioffi, MS (Department of Health Care Policy, Harvard Medical School) and Cashel O’Brien, BS (Division of Cardiology, Massachusetts General Hospital, Harvard Medical School) assisted in the preparation of the manuscript. No specific financial compensation was provided for their contributions to this study.

Yeh  RW, Sidney  S, Chandra  M, Sorel  M, Selby  JV, Go  AS.  Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med. 2010;362(23):2155-2165.
PubMed   |  Link to Article
Boden  WE, O’Rourke  RA, Teo  KK,  et al; COURAGE Trial Research Group.  Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-1516.
PubMed   |  Link to Article
US Census Bureau, Population Division. Annual estimates of the resident population by single year of age and sex for the United States, States, and Puerto Rico Commonwealth: April 1, 2010, to July 1, 2012. June 2013. http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk. Accessed November 13, 2014.
Roger  VL, Weston  SA, Gerber  Y,  et al.  Trends in incidence, severity, and outcome of hospitalized myocardial infarction. Circulation. 2010;121(7):863-869.
PubMed   |  Link to Article
Yeh  RW, Normand  SL, Wang  Y, Barr  CD, Dominici  F.  Geographic disparities in the incidence and outcomes of hospitalized myocardial infarction: does a rising tide lift all boats? Circ Cardiovasc Qual Outcomes. 2012;5(2):197-204.
PubMed   |  Link to Article
Patel  MR, Dehmer  GJ, Hirshfeld  JW, Smith  PK, Spertus  JA; American College of Cardiology Foundation Appropriateness Criteria Task Force; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; American Association for Thoracic Surgery; American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography; Heart Failure Society of America; Society of Cardiovascular Computed Tomography.  ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization. J Am Coll Cardiol. 2009;53(6):530-553.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Temporal Trends in Population-Wide Rates of Coronary Revascularization in Massachusetts, 2003-2012

Rates reflect the number of unique individuals undergoing revascularization in a given year, per 100 000 residents, and are adjusted for age and sex. CABG indicates coronary artery bypass graft surgery; and PCI, percutaneous coronary intervention.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Temporal Trends in Rates of PCI and CABG, Stratified by Presentation With or Without MI

Rates reflect the number of unique individuals with and without MI undergoing PCI or CABG in a given year, per 100 000 residents, and are adjusted for age and sex. CABG indicates coronary artery bypass graft surgery; MI, myocardial infarction; and PCI, percutaneous coronary intervention.

Graphic Jump Location

Tables

References

Yeh  RW, Sidney  S, Chandra  M, Sorel  M, Selby  JV, Go  AS.  Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med. 2010;362(23):2155-2165.
PubMed   |  Link to Article
Boden  WE, O’Rourke  RA, Teo  KK,  et al; COURAGE Trial Research Group.  Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-1516.
PubMed   |  Link to Article
US Census Bureau, Population Division. Annual estimates of the resident population by single year of age and sex for the United States, States, and Puerto Rico Commonwealth: April 1, 2010, to July 1, 2012. June 2013. http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk. Accessed November 13, 2014.
Roger  VL, Weston  SA, Gerber  Y,  et al.  Trends in incidence, severity, and outcome of hospitalized myocardial infarction. Circulation. 2010;121(7):863-869.
PubMed   |  Link to Article
Yeh  RW, Normand  SL, Wang  Y, Barr  CD, Dominici  F.  Geographic disparities in the incidence and outcomes of hospitalized myocardial infarction: does a rising tide lift all boats? Circ Cardiovasc Qual Outcomes. 2012;5(2):197-204.
PubMed   |  Link to Article
Patel  MR, Dehmer  GJ, Hirshfeld  JW, Smith  PK, Spertus  JA; American College of Cardiology Foundation Appropriateness Criteria Task Force; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; American Association for Thoracic Surgery; American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography; Heart Failure Society of America; Society of Cardiovascular Computed Tomography.  ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization. J Am Coll Cardiol. 2009;53(6):530-553.
PubMed   |  Link to Article

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