Advertisement

Influence of regional cardiovascular mortality on the use of angiography after acute myocardial infarction

      This paper is only available as a PDF. To read, Please Download here.

      Abstract

      Utilization of angiography after acute myocardial infarction (AMI) treated with thrombolytics has been shown in large clinical trials to be related primarily to the availability of the procedure and not individual clinical circumstances. This study evaluated the regional influence of overall population cardiovascular mortality on utilization of angiography in the United States participants of the Global Utilization of Streptokinase and t-PA for Occluded Arteries (GUSTO-1) trial. Published summary statistics from GUSTO-1 and U.S. Census Bureau 1991 data were evaluated using simple and multiple linear regression with analysis for outliers. Region predictor variables (age adjusted) included mean total cardiovascular deaths/100,000/year (ICD/9 codes 390 to 459), mean coronary artery disease deaths/ 100,000/year (ICD/9 codes 410 to 414), and mean stroke deaths/100,000/year (ICD/9 codes 430 to 438), with the major outcome being regional proportion of GUSTO-1 patients undergoing angiography during the hospital stay after treatment with thrombolysis. All 3 cardiovascular death rates varied significantly by region (p < 0.00002) with no significant difference in GUSTO-1 mortality by region (p = 0.25). Simple linear regression analysis revealed associations between regional death rates and angiography use (r = 0.60, p = 0.12; r = 0.39, p = 0.33; r = 0.81, and p = 0.015). Multiple stepwise linear regression analysis found regional death rate due to stroke as the strongest predictor of angiography use with 65.86% of the variation explained by the model. New England was found to be a consistent outlier with reduced angiography use because of its background regional disease burden. This study confirms regional bias in the use of angiography in GUSTO-1. This form of operator bias appears to be due to more aggressive practice patterns in regions, except New England, where the overall cardiovascular disease burden is greater in terms of lives lost per 100,000 per year.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Spertus JA
        • Weiss NS
        • Every NR
        • Weaver WD
        The influence of clinical risk factors on the use of angiography and revascularization after myocardial infarction.
        Arch Intern Med. 1995; 155: 2309-2316
        • Pilote L
        • Califfe RM
        • Sapp S
        • Miller DP
        • Mark DB
        • Weaver WD
        • Gore JM
        • Armstrong PW
        • Ohman EM
        • Topol EJ
        Regional variation across the United States in the management of acute myocardial infarction.
        N Engl J Med. 1995; 333: 565-572
        • Every NR
        • Larson EB
        • Litwin PE
        • Maynard C
        • Fihn SD
        • Eisenberg MS
        • Hallstrom AP
        • Martin JS
        • Weaver WD
        The association between on-site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarction. Myocardial Infarction Triage and Intervention Project Investigators.
        N Engl J Med. 1993; 329: 546-551
        • Guadagnoli E
        • Hauptman PJ
        • Ayanian JZ
        • Pashos CL
        • McNeil BJ
        • Cleary PD
        Variation in the use of cardiac procedures after acute myocardial infarction.
        N Engl J Med. 1995; 333: 573-578
        • The GUSTO Investigators
        An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction.
        New Engl J Med. 1993; 329: 673-682
        • American Heart Association
        Heart and Stroke Facts: 1995 Statistical Supplement.
        in: 1995: 6-7
        • U.S. Department of Health and Human Services
        • Public Health Service
        • Centers For Disease Control and Prevention
        • National Center For Health Statistics
        Final 1991 state mortality. Population-state estimates by age and sex: 1980–1992, current population reports.
        Series P-25. 1993;
        • Neter J
        • Wasserman W
        • Kutner MH
        Diagnostics and remedial measures II.
        in: Anonymous Applied Linear Statistical Models: Regression, Analysis of Variance, and Experimental Designs. Third Ed. Richard D. Irwin, Inc., Boston1990: 386-432
        • Every NR
        • Fihn SD
        • Maynard C
        • Martin JS
        • Weaver WD
        Resource utilization in treatment of acute myocardial infarction: staff-model health maintenance organization versus fee-for-service hospitals. The MITI Investigators. Myocardial Infarction Triage and Intervention.
        J Am Coll Cardiol. 1995; 26: 401-406
        • Blustein J
        • Weitzman BC
        Access to hospitals with high-technology cardiac services: how is race important?.
        Am J Public Health. 1995; 85: 345-351