Key result
On-site cardiac services increased angiography use for patients with uncertain benefit (RR 0.92 vs 0.58 at hospitals without services, p<0.001) but did not improve one-year survival.
Why the study?
Does the availability of on-site cardiac services affect case-selection for angiography and one-year survival in elderly patients with acute myocardial infarction?
Cohort (n=37,788)
Yes
Does the availability of on-site cardiac services affect case-selection for angiography and one-year survival in elderly patients with acute myocardial infarction?
Effect estimate: RR 0.58, 0.79, and 0.92
p-value: p=< 0.001
Increased availability of on-site cardiac services leads to higher rates of angiography in patients with uncertain clinical benefit, without an associated improvement in one-year survival.
May promote angiography overuse in uncertain-benefit AMI without survival gains; leaves open whether refined selection improves outcomes.
OBJECTIVE: To examine whether availability of cardiac services at the admitting hospital affects case-selection for angiography and one-year survival following angiography, within groups of patients who have similar clinical need for angiography according to published criteria. STUDY SETTING: Elderly Medicare beneficiaries (37,788) discharged with a diagnosis of acute myocardial infarction (AMI) from hospitals in seven U.S. states between February 1994 and July 1995. We focused on patients who were eligible to receive angiography 12 or more hours after symptom onset. DATA COLLECTION: Data were abstracted from patient's medical records, Medicare National Claims Standard Analytic Files, Health Care Financing Administration (HCFA) Provider of Service File and Health Insurance Master File. METHODS: Admitting hospitals were classified as offering no cardiac services, angiography only, or revascularization. Case-selection differences across these three types of hospitals were examined by comparing relative risk of receiving angiography for various patient and hospital characteristics. Relative differences in one-year survival rate, comparing patients who received angiography to those who did not, were estimated within each hospital type and clinical need category (necessary, appropriate, or uncertain) after matching on propensity to receive angiography. PRINCIPAL FINDINGS: Compared to patients for whom angiography was deemed necessary, the relative risk of receiving angiography among those for whom it was deemed of uncertain benefit was 0.58, 0.79, and 0.92 (p-value of homogeneity test < 0.001) at hospitals offering no cardiac services, angiography only, and revascularization, respectively. There was no significant difference in survival following angiography across hospital types, overall as well as within clinical need categories. CONCLUSIONS: Despite increased case selection at hospitals with on-site cardiac services, there was no evidence of increase in the survival rate associated with angiography use at these hospitals.
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Dendukuri et al. (2003) conducted a cohort in Acute myocardial infarction (AMI) (n=37,788). On-site cardiac services (angiography or revascularization) vs. Hospitals offering no cardiac services was evaluated on Relative risk of receiving angiography for patients with uncertain benefit compared to necessary benefit (RR 0.58, 0.79, and 0.92, p=< 0.001). On-site cardiac services increased angiography use for patients with uncertain benefit (RR 0.92 vs 0.58 at hospitals without services, p<0.001) but did not improve one-year survival.
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