Variation and Temporal Trends in the Use of Diagnostic Testing During Hospitalization for Acute Myocardial Infarction by Age, Gender, Race, and Geography (the Atherosclerosis Risk In Communities Study)

      The use of cardiovascular procedures has become routine in the management of acute myocardial infarction (MI). However, diagnostic testing beyond coronary revascularization procedures and use over time has not been well characterized. Records of 35- to 74-year-old adults hospitalized with MI in 4 US communities from 1987 to 2001 were abstracted using standardized data collection methods. Rates of procedure use and outcomes were compared by patient characteristics. Of 11,242 patients (mean age 61 years, 43% women, 22% black), angiography use increased substantially over time, echocardiography use increased more in women than men (interaction p <0.05), use of right-sided cardiac catheterization decreased, and use of nuclear scans and exercise tests remained constant. Men, whites, and locations with the highest angiography and right-sided cardiac catheterization use had lower noninvasive testing. In multivariate analysis, women had less angiograms and more echocardiograms obtained than men, but only in those with no previous MI before this hospitalization (both interaction p <0.05). Similarly, in those without previous MI, blacks were even less likely than whites to undergo angiography compared with those with a history of MI (interaction p = 0.0001). Adjusted mortality rates were similar by gender, but mortality was higher in blacks than whites, a difference that decreased with adjustment for angiography use. In conclusion, in patients hospitalized with MI, use of many diagnostic cardiovascular procedures varied over time, with differences by gender, age, race, and geography that persisted over time unexplained by many measurable characteristics. There may also be continued perception of lower risk in women and blacks without a known diagnosis of MI.
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        • The ARIC Investigators
        The Atherosclerosis Risk In Communities (ARIC) Study: design and objectives.
        Am J Epidemiol. 1989; 129: 687-702
        • White A.D.
        • Folsom A.R.
        • Chambless L.E.
        • Sharret A.R.
        • Yang K.
        • Conwill D.
        • Higgins M.
        • Williams O.D.
        • Tyroler H.A.
        Community surveillance of coronary heart disease in the Atherosclerosis Risk in Communities (ARIC) Study: methods and initial two years' experience.
        J Clin Epidemiol. 1996; 49: 223-233
        • Lucas F.L.
        • Wennberg D.E.
        • Malenka D.J.
        Variation in the use of echocardiography.
        Eff Clin Pract. 1999; 2: 71-75
        • Chiriboga D.E.
        • Yarzebski J.
        • Goldberg R.J.
        • Chen Z.
        • Gurwitz J.
        • Gore J.M.
        • Alpert J.S.
        • Dalen J.E.
        A community-wide perspective of gender differences and temporal trends in the use of diagnostic and revascularization procedures for acute myocardial infarction.
        Am J Cardiol. 1993; 71: 268-273
        • Connors Jr, A.F.
        • Speroff T.
        • Dawson N.V.
        • Thomas C.
        • Harrell Jr, F.E.
        • Wagner D.
        • Desbiens N.
        • Goldman L.
        • Wu A.W.
        • Califf R.M.
        • et al.
        The effectiveness of right heart catheterization in the initial care of critically ill patients.
        JAMA. 1996; 276: 889-897
        • Shah M.R.
        • Hasselblad V.
        • Stevenson L.W.
        • Binanay C.
        • O'Connor C.M.
        • Sopko G.
        • Califf R.M.
        Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials.
        JAMA. 2005; 294: 1664-1670
        • Harrold L.R.
        • Esteban J.
        • Lessard D.
        • Yarzebski J.
        • Gurwitz J.H.
        • Gore J.M.
        • Goldberg R.J.
        Narrowing gender differences in procedure use for acute myocardial infarction: insights from the Worcester heart attack study.
        J Gen Intern Med. 2003; 18: 423-431
        • Vaccarino V.
        • Rathore S.S.
        • Wenger N.K.
        • Frederick P.D.
        • Abramson J.L.
        • Barron H.V.
        • Manhapra A.
        • Mallik S.
        • Krumholz H.M.
        Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002.
        N Engl J Med. 2005; 353: 671-682
        • Conigliaro J.
        • Whittle J.
        • Good C.B.
        • Hanusa B.H.
        • Passman L.J.
        • Lofgren R.P.
        • Allman R.
        • Ubel P.A.
        • O'Connor M.
        • Macpherson D.S.
        Understanding racial variation in the use of coronary revascularization procedures: the role of clinical factors.
        Arch Intern Med. 2000; 160: 1329-1335
        • Ferguson J.A.
        • Tierney W.M.
        • Westmoreland G.R.
        • Mamlin L.A.
        • Segar D.S.
        • Eckert G.J.
        • Zhou X.H.
        • Martin D.K.
        • Weinberger M.
        Examination of racial differences in management of cardiovascular disease.
        J Am Coll Cardiol. 1997; 30: 1707-1713
        • Chen J.
        • Rathore S.S.
        • Radford M.J.
        • Wang Y.
        • Krumholz H.M.
        Racial differences in the use of cardiac catheterization after acute myocardial infarction.
        N Engl J Med. 2001; 344: 1443-1449
        • Whittle J.
        • Conigliaro J.
        • Good C.B.
        • Joswiak M.
        Do patient preferences contribute to racial differences in cardiovascular procedure use?.
        J Gen Intern Med. 1997; 12: 267-273
        • Rathore S.S.
        • Ordin D.L.
        • Krumholz H.M.
        Race and sex differences in the refusal of cardiac catheterization among elderly patients hospitalized with acute myocardial infarction.
        Am Heart J. 2002; 144: 1052-1056
        • Ayanian J.Z.
        • Epstein A.M.
        Attitudes about treatment of coronary heart disease among women and men presenting for exercise testing.
        J Gen Intern Med. 1997; 12: 311-314
        • Rathore S.S.
        • Masoudi F.A.
        • Havranek E.P.
        • Krumholz H.M.
        Regional variations in racial differences in the treatment of elderly patients hospitalized with acute myocardial infarction.
        Am J Med. 2004; 117: 811-822
        • Guadagnoli E.
        • Hauptman P.J.
        • Ayanian J.Z.
        • Pashos C.L.
        • McNeil B.J.
        • Cleary P.D.
        Variation in the use of cardiac procedures after acute myocardial infarction.
        N Engl J Med. 1995; 333: 573-578
        • Wenneker M.B.
        • Weissman J.S.
        • Epstein A.M.
        The association of payer with utilization of cardiac procedures in Massachusetts.
        JAMA. 1990; 264: 1255-1260
        • Whittle J.
        • Conigliaro J.
        • Good C.B.
        • Lofgren R.P.
        Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system.
        N Engl J Med. 1993; 329: 621-627
        • Peterson E.D.
        • Shaw L.K.
        • DeLong E.R.
        • Pryor D.B.
        • Califf R.M.
        • Mark D.B.
        Racial variation in the use of coronary-revascularization procedures.
        N Engl J Med. 1997; 336: 480-486
        • Selby J.V.
        • Fireman B.H.
        • Lundstrom R.J.
        • Swain B.E.
        • Truman A.F.
        • Wong C.C.
        • Froelicher E.S.
        • Barron H.V.
        • Hlatky M.A.
        Variation among hospitals in coronary-angiography practices and outcomes after myocardial infarction in a large health maintenance organization.
        N Engl J Med. 1996; 335: 1888-1896
        • Healy B.
        The Yentl syndrome.
        N Engl J Med. 1991; 325: 274-276
        • Steingart R.M.
        • Packer M.
        • Hamm P.
        • Coglianese M.E.
        • Gersh B.
        • Geltman E.M.
        • Sollano J.
        • Katz S.
        • Moye L.
        • Basta L.L.
        Sex differences in the management of coronary artery disease.
        N Engl J Med. 1991; 325: 226-230
        • Maynard C.
        • Litwin P.E.
        • Martin J.S.
        • Weaver W.D.
        Gender differences in the treatment and outcome of acute myocardial infarction.
        Arch Intern Med. 1992; 152: 972-976
        • Wennberg D.E.
        • Kellett M.A.
        • Dickens J.D.
        • Malenka D.J.
        • Keilson L.M.
        • Keller R.B.
        The association between local diagnostic testing intensity and invasive cardiac procedures.
        JAMA. 1996; 275: 1161-1164
        • Feigenbaum H.
        Evolution of echocardiography.
        Circulation. 1996; 93: 1321-1327
        • Kim R.
        • Chakko S.
        • Myerburg R.J.
        • Kessler K.M.
        Clinical usefulness and cost of echocardiography in patients admitted to a coronary care unit.
        Am J Cardiol. 1997; 80: 1273-1276