Hospital Patterns of Medical Management Strategy Use for Patients With Non–ST-Elevation Myocardial Infarction and 3-Vessel or Left Main Coronary Artery Disease

Ralf E. Harskamp, MD; Tracy Y. Wang, MD, MHS, MSc; Deepak L. Bhatt, MD, MPH; Stephen D. Wiviott, MD; Ezra A. Amsterdam, MD; Shuang Li, MS; Laine Thomas, PhD; Robbert J. de Winter, MD, PhD; Matthew T. Roe, MD, MHS

Disclosures

Am Heart J. 2014;167(3):355-362. 

In This Article

Results

Hospital-level use of Medical Management and Temporal Trends

Among the overall population of 42,535 patients with 3VD/LMD from 423 hospitals, 7,487 patients (17.6%: interquartile range 16%-19.4%) were medically managed. The remaining patients were treated with either surgical or percutaneous coronary revascularization. The proportion of patients who were medically managed remained relatively stable during each quarter of the analysis, with no significant change over time (Figure 2, P for trend = 0.11). Nevertheless, we observed temporal shifts in the use patterns of PCI and CABG over this time period.

Figure 2.

Trends in the Use of Medical Management, PCI, and CABG. This figure displays the percentage of patients treated with a medical management strategy, PCI, and CABG for each quarter between January 1, 2007 and March 31, 2012, at 423 hospitals in the U.S. Cochran-Armitage Trend test for medical management one-sided P: .11, for PCI: P < .001, for CABG: P < .001. CABG, coronary artery bypass grafting; MMS, medical management strategy; PCI, percutaneous coronary intervention; U.S. United States.

Among the primary analysis cohort of 316 hospitals treating at least 25 patients throughout the duration of the study period, the hospital-level use of MMS varied widely (median 17.1%, range 0–44.8%, P < .0001; Figure 3). A similar variation in MMS use was found in the sensitivity analysis that assessed MMS use at 69 hospitals that consistently submitted data every quarter to the ACTION Registry–GWTG during the 5-year analysis time period (Figure 4).

Figure 3.

Hospital-level Variation of Medical Management Use Among All 316 Hospitals. Hospital-level variation of medical management use (%) with 95% CI over the 5-year analysis time period (2007–2012) in 316 hospitals with an adequate volume of NSTEMI patients. CI, confidence interval; NSTEMI, non–ST-segment elevation myocardial infarction.

Figure 4.

Hospital-level Variation of Medical Management Use in Consistently Reporting Hospitals. Hospital-level variation of medical management use (%) with 95% CI over the 5-year analysis time period (2007–2012) for the 69 hospitals with an adequate volume of patients that consistently submitted data to ACTION Registry–GWTG for each quarter.

Hospital Characteristics

As shown in Table I, hospitals in the lowest tertile of MMS use were more likely to be located in the western region whereas hospitals in the highest tertile of MMS use were more likely to be located in the southern region. Additionally, hospitals in the highest tertile of MMS use were more likely to have an academic affiliation. Finally, hospitals in the middle tertile of MMS use had the highest annual volume of CABG procedures.

Patient Characteristics

Patients who were medically managed were older, more frequently African-American, and more frequently presented with congestive heart failure compared with patients who subsequently underwent PCI or CABG surgery after coronary angiography (online Appendix). These patients were more frequently insured by Medicare or Medicaid and less often with private insurance. Apart from smoking, other cardiovascular risk factors were all more prevalent in patients with a MMS. Therefore, the predicted and observed unadjusted mortality was about three times higher compared with patients who underwent coronary revascularization (7.8% vs. 2.6% after PCI and 3.0% after CABG).

Patient Characteristics Across Hospital Tertiles. Differences in patient baseline characteristics were also demonstrated across hospital tertiles, with a higher proportion of African-American and uninsured patients among hospitals that were in the highest tertile of MMS use (Table II). Isolated left-main disease, without significant disease in the 3 major epicardial vessels, occurred in a minority of patients and was similar across hospital tertiles (low MMS use: 4.9%, intermediate MMS use: 4.7%, high MMS use: 5.1%, P = .17). The predicted mortality risk was similar across hospital tertiles and unadjusted in-hospital mortality rates were <4% in each tertile. The use of both PCI and CABG was highest for patients from hospitals in the lowest tertile of MMS use, with sequential decreases in the use of both types of revascularization procedures, from the lowest to highest tertiles. Discharge medications and interventions were utilized to a similar extent across hospital tertiles, with the exception of cardiac rehabilitation referral, which was most commonly utilized among hospitals in the lowest tertile of MMS use.

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