Trends in Coronary Revascularization Procedures

One of the most common major medical procedures provided by the healthcare system in the United States, coronary revascularization, is performed >1 million times each year. The procedure comprises coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI). Coronary revascularization is also among the most costly procedures in the United States; Medicare inpatient payments to hospitals for the procedure were >$6.7 billion in fiscal year 2006, more than the amount of reimbursement for any other medical or surgical procedure. In the past 10 years, innovations in coronary revascularization have included use of drug-eluting stents (DES), minimally invasive CABG surgery, and “off-pump” CABG surgery. The 2007 Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial provided information about the clinical value of revascularization compared with pharmacotherapy in addition to assessing the outcomes of CABG surgery compared with PCI in the DES era. According to researchers, it is uncertain how the new technologies, new clinical evidence from trials, and updated clinical guidelines have influenced the volume and distribution of coronary revascularizations over the past decade. They recently conducted a study to examine national trends in the rates and types of coronary revascularization. Study results were reported in the Journal of the American Medical Association [2011;305(17):1769-1776]. The study utilized data on patients undergoing CABG surgery or PCI between 2001 and 2008 in the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample. Data from Medicare inpatient claims were also included in the analysis. The primary outcome measures were the annual procedure rates of coronary revascularizations, CABG surgery, and PCI. The US rate of coronary revascularizations decreased by 15% from 5569 (95% confidence interval [CI], 5315-5835) procedures per million adults per year in 2001-2002 to 4748 (95% CI, 4532-4975) procedures per million adults per year in 2007-2008. There was a 38% decrease in the annual CABG surgery rate between 2001 and 2008; the CABG surgery rate decreased steadily throughout the 8-year period from 1742 (95% CI, 1663-1825) per million adults per year in 2001-2002 to 1081 (95% CI, 1032-1133) per million adults per year in 2007-2008 (P<.001). However, there was only a minimal change in the PCI rate; the rate of PCI had a 4% decrease from 3827 (95% CI, 3578-4092) per million adults per year in 2001-2002 to 3667 (95% CI, 3429-3922) per million adults per year in 2007-2008. When projected to the total population of the United States, the changes in rates implied that 130,000 fewer CABG surgeries were performed in 2008 compared with 2001. Likewise, the 2001-2008 decrease in the total number of US coronary revascularizations was 80,000 (7%) from a 2001 total volume of 1.21 million revascularizations. In 2001, there were 212 hospitals in the Nationwide Inpatient Sample providing CABG surgery; in 2008, there were 241, an increase of 12% (P=.03). The number of hospitals performing PCI also increased, from 246 in 2001 to 331 in 2008, a 26% increase (P<.001). Over the same time period, the median CABG surgery caseload decreased from 253 to 183 (28% decrease; P<.001). The number of CABG surgery hospitals performing <100 CABG surgeries per year increased from 23 in 2001 to 62 in 2008 (P<.001). In summary, the researchers stated, “In US hospitals between 2001 and 2008, a substantial decrease in CABG surgery utilization rates was observed, but PCI utilization rates remained unchanged.”