A.M. Yip

Determinants of Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting: An Interprovincial Comparison

BACKGROUND Marked variation exists concerning the utilization of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). The objective of this study was to examine differences in predictors of mode of revascularization across 3 provincial jurisdictions. METHODS All patients who underwent PCI and isolated CABG in British Columbia, Alberta, and Nova Scotia between 1996 and 2007 were considered. Age- and sex-standardized rates of PCI and CABG per 100,000 population and PCI to CABG ratios were calculated by year and province. Logistic regression models were constructed to identify independent predictors of mode of revascularization in each province. RESULTS A total of 32,190 and 69,409 patients underwent CABG and PCI, respectively, during the study period. Significant increases in the age- and sex-adjusted PCI to CABG ratios were observed in all 3 provinces, but these ratios differed between provinces. Across all 3 jurisdictions, female sex and diagnosis of acute coronary syndrome favoured increased PCI vs CABG, and increased age, left main, or 3-vessel disease occurring before myocardial infarction, and diabetes favoured lower PCI vs CABG. After adjusting for clinical and angiographic factors, there remained a significant variation in choice of PCI vs CABG between the 3 provinces over time. CONCLUSIONS Significant interprovincial variability in PCI to CABG ratios was observed. Though certain patient-related factors predictive of either PCI or CABG were identified, factors beyond clinical presentation played a role in the choice of revascularization approach.

Increased Distance From the Tertiary Cardiac Center Is Associated With Worse 30-Day Outcomes After Cardiac Operations.

BACKGROUND Numerous studies have examined the effect of geographic place of residence on access to cardiovascular care, but few have examined their effect on outcomes after cardiac operations. This study examined the effect of geographic place of residence on in-hospital and 30-day outcomes after cardiac operations. METHODS We performed a retrospective analysis of all patients undergoing nonemergency cardiac operations at a single institution between April 2004 and March 2011. Geographic place of residence was defined as the driving distance from the patients home to the tertiary cardiac care center divided into the following categories: 0 to 50 km, 50 to 100 km, 100 to 150 km, 150 to 200 km, 200 to 250 km, and more than 250 km. Multivariable logistic regression was used to determine the independent effect of driving distance on in-hospital and 30-day outcomes. RESULTS The final study population included 4,493 patients, of whom 3,897 (86.7%) had 30-day follow-up. After adjusting for differences among patient groups, no consistent relationship existed between distance and in-hospital outcomes. However, increased distance beyond 100 km was significantly associated with a greater risk of adverse outcomes at 30 days (0 to 50 km: referent; 50 to 100 km: odds ratio, 1.16 [95% confidence interval, 0.83 to 1.62]; 100 to 150 km: 1.32 [1.05 to 1.65], 150 to 200 km: 1.68 [1.33 to 2.11], 200 to 250 km: 1.41 [1.06 to 1.88], and >250 km: 1.30 [1.04 to 1.63]). CONCLUSIONS Patients who live at an increased distance from the tertiary cardiac care center are more likely to have worse 30-day outcomes after cardiac operations. Further study is required to determine the mechanisms underlying this relationship and how such inequalities may be minimized.