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CLINICAL RESEARCH: ACUTE MYOCARDIAL INFARCTION

Regional Variation in Cardiac Catheterization Appropriateness and Baseline Risk After Acute Myocardial Infarction

Dennis T. Ko, MD, MSc^_*,,1,_*, Yongfei Wang, MS, David A. Alter, MD, PhD^,2, Jeptha P. Curtis, MD, Saif S. Rathore, MPH, Therese A. Stukel, PhD, Fredrick A. Masoudi, MD, MSPH, FACC, Joseph S. Ross, MD, MHS^||,3, JoAnne M. Foody, MD, FACC and Harlan M. Krumholz, MD, SM, FACC^,¶

^_* Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
Department of Medicine, Denver Health Medical Center, and Department of Medicine, University of Colorado Health Sciences Center, Denver, Colorado
^|| Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, New York, and Geriatrics Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York
^¶ Section of Health Policy and Administration, Department of Epidemiology and Public Health, Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.

Manuscript received July 27, 2007; revised manuscript received September 19, 2007, accepted October 1, 2007.

^_* Reprint requests and correspondence: Dr. Dennis Ko, Institute for Clinical Evaluative Sciences G1 06, 2075 Bayview Ave, Toronto, Ontario, Canada M4N 3M5. (Email: dennis.ko{at}ices.on.ca).

Objectives: We evaluated whether appropriateness and baseline risk of cardiac catheterization varied according to regional intensity of invasive therapy after acute myocardial infarction (AMI), and whether AMI mortality varied according to invasive intensity regions.

Background: Marked regional variations exist in cardiac invasive procedure use after AMI within the U.S.

Methods: We performed an analysis of 44,639 Medicare fee-for-service beneficiaries hospitalized with AMI between 1998 and 2001. Invasive procedure intensity was determined based on overall cardiac catheterization rates for Medicare enrollees. Cardiac catheterization appropriateness was determined by the American College of Cardiology/American Heart Association classification and baseline risk was estimated using the GRACE (Global Registry of Acute Coronary Events) risk score. The primary outcomes of the study were cardiac catheterization use within 60 days and 3-year mortality after hospital admission.

Results: Higher invasive intensity regions were more likely to perform cardiac catheterizations on class I patients (appropriate) (RR 1.38, 95% confidence interval [CI] 1.27 to 1.48), class II patients (equivocal) (RR 1.42, 95% CI 1.31 to 1.53), and class III patients (inappropriate) (RR 1.29, 95% 0.97 to 1.67) compared with low-intensity regions after adjusting for patient and physician characteristics. The overall cardiac catheterization use was 5.2% lower for each increase in GRACE risk decile, and this relationship was observed similarly in all regions. Risk-standardized mortality rates of AMI patients at 3 years were not substantially different between regions.

Conclusions: Although higher-risk patients and those with more appropriate indications may have the most to benefit from an invasive strategy after AMI, we found that higher-invasive regions do not differentiate procedure selection based on the patients’ appropriateness or their baseline risks.

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/American Heart Association   AMI = acute myocardial infarction   LDH = lactate dehydrogenase   NHC = National Heart Care

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