Coronary Revascularization Performed Less Frequently

The overall number of coronary revascularization procedures—PCI and CABG—performed among Medicare beneficiaries declined over a recent 5-year period, according to a large study published online December 22, 2014, ahead of print in Circulation.

Furthermore, a similar drop was seen over the course of about a decade in a broader population in Massachusetts, reports a research letter published online January 5, 2015, ahead of print in JAMA Internal Medicine.

For the first study, Steven D. Culler, PhD, of Emory University (Atlanta, GA), and colleagues retrospectively examined 2,768,007 records of Medicare beneficiaries from 2008 through 2012. The information came from 2 administrative data sets covering inpatient and outpatient claims: the Medicare Provider Analysis and Review (MedPAR) file and the Medicare Outpatient Payment file.

Medicare Procedure Volumes, Outcomes Change Over Time

During the study period, there was a rise in the number of nonadmission PCIs (from 60,405 in 2008 to 106,495 in 2012). That increase, however, was more than offset by a decrease in PCIs requiring admission (from 363,384 to 295,434 over the same time period).

Accompanying the fall in overall PCI volume was a decrease of 18,380 CABG admissions from 2008 to 2012, a 13.1% drop.

Even though procedure volumes fell during the study period, the number of facilities equipped to perform revascularizations increased. By 2012, there were 268 more sites performing nonadmission PCI, 136 more performing inpatient PCI, and 19 more performing CABG surgery. The 2 opposing trends resulted in reductions in the average number of procedures performed per facility over time for both PCI (of about 32 per center) and CABG (of about 17 per center).

Changes also were seen in outcomes. For PCI overall, rates of mortality during hospitalization (or before leaving the PCI center for nonadmission procedures) remained stable at about 1.7% for the first 3 years of the study period before increasing by about 0.1% per year for the next 2 years. There was a slight fall in mortality accompanying nonadmission PCIs (from 0.32% to 0.27%) but an increase in mortality for inpatient PCI (from 1.9% to 2.5%).

For CABG, the overall mortality rate declined from 3.7% in 2008 to 3.2% in 2012.

When looking at mortality for PCI and CABG combined, however, the rates—which were not adjusted for changes in illness severity over time—remained relatively stable between 2.1% and 2.2% each year.

The changes in death rates varied by patient presentation, with STEMI patients seeing an increase in mortality over time for all inpatient revascularization. In contrast, mortality rates declined among NSTEMI patients. For patients presenting without an acute MI, mortality fell for CABG and nonadmission PCI procedures but rose for PCI admissions.

Similar Trends Seen in Massachusetts

For the second study, Robert W. Yeh, MD, MSc, of Massachusetts General Hospital (Boston, MA), and colleagues looked at data from all state residents undergoing revascularization at nonfederal hospitals from April 2003 to September 2012. The analysis included 171,702 revascularizations (76.9% PCI and 23.1% CABG).

As with the Medicare study, revascularizations became less frequent over time. The age- and sex-adjusted rate of any revascularization fell from 423 to 258 per 100,000 residents over the course of the study period (P < .001), with declines seen for both PCI and CABG and elective and urgent procedures. Isolated CABG became less common, mirroring the overall trend, but the rate of combined CABG and aortic or mitral valve surgery remained stable.

Dr. Yeh and colleagues say multiple factors likely are responsible, including declining rates of MI, publication of the COURAGE trial, and increasing attention to the appropriate use of PCI.

Reversal In Sight?

Dr. Culler and colleagues hypothesize that the observed declines in procedure volumes will likely reverse in the coming years as baby boomers continue to enter the Medicare program “unless there are significant changes in Medicare beneficiaries’ lifestyle, behavior, or new noninvasive treatments that delay or reduce the incidence of coronary artery disease.”

Fortunately, they write, the expansion in the number of facilities performing revascularizations “indicates that the US delivery system already has the capacity to handle any expected increase in the demand for revascularization procedures from future Medicare beneficiaries based on recommended annual revascularization volume levels.”

Yet Timothy J. Gardner, MD, of the Christiana Care Health System (Wilmington, DE), questions the idea that procedure volumes will increase in an editorial accompanying the Circulation study.

“An alternate conclusion from this report… is that the declining utilization rates of revascularization either by PCI or CABG seen clearly over this recent 5-year period may predict a continued decline in total Medicare revascularizations even in an expanding Medicare population,” he writes. “It would require actuarial techniques to plot the declining utilization trends in revascularizations against expanding numbers of [Medicare beneficiaries]. It is quite possible, however, based on clear treatment trends favoring noninvasive treatments, appropriate use initiatives, palliative care, and patient empowerment programs, that a decline in revascularization for Medicare patients, as observed in this analysis, portends a continued reduction in the future.”

The decline in overall revascularizations, Dr. Gardner notes, “may be the most important finding in this report and the specific trend indicator that requires careful documentation in future analyses.”

 

 

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Sources:

1. Culler SD, Kugelmass AD, Brown PP, et al. Trends in coronary revascularization procedures among Medicare beneficiaries between 2008 and 2012. Circulation. 2014;Epub ahead of print.
2. Yeh RW, Mauri L, Wolf RE, et al. Population trends in rates of coronary revascularization [research letter]. JAMA Intern Med. 2015;Epub ahead of print.
3. Gardner TJ. Declining utilization rates of revascularization for Medicare patients: is this a real trend [editorial]? Circulation. 2014;Epub ahead of print.