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Comparative Study
. 2013 Jan 1;6(1):11-9.
doi: 10.1161/CIRCIMAGING.112.974121. Epub 2012 Oct 16.

Patterns of stress testing and diagnostic catheterization after coronary stenting in 250 350 medicare beneficiaries

Daniel W Mudrick  1 , Bimal R Shah, Lisa A McCoy, Barbara L Lytle, Frederick A Masoudi, Jerome J Federspiel, Patricia A Cowper, Cynthia Green, Pamela S Douglas
Affiliations
Comparative Study

Patterns of stress testing and diagnostic catheterization after coronary stenting in 250 350 medicare beneficiaries

Daniel W Mudrick et al. Circ Cardiovasc Imaging. .

Erratum in

  • Circ Cardiovasc Imaging. 2013 May 1;6(3):e21

Abstract

Background: Patterns of noninvasive stress test (ST) and invasive coronary angiography (CA) utilization after percutaneous coronary intervention (PCI) are not well described in older populations.

Methods and results: We linked National Cardiovascular Data Registry CathPCI Registry data with longitudinal Medicare claims data for 250 350 patients undergoing PCI from 2005 to 2007 and described subsequent testing and outcomes. Between 60 days post-PCI and end of follow-up (median 24 months), 49% (n=122 894) received ST first, 10% (n=25 512) underwent invasive CA first, and 41% (n=101 944) had no testing. Several clinical risk factors at time of index PCI were associated with decreased likelihood of downstream testing (ST or CA, P<0.05 for all), including older age (hazard ratio [HR] 0.784 per 10-year increase), male sex (HR 0.946), heart failure (HR 0.925), diabetes mellitus (HR 0.954), smoking (HR 0.804), and renal failure (HR 0.880). Fifteen percent of patients with ST first proceeded to subsequent CA within 90 days of testing (n=18 472/122 894) [corrected]; of these, 48% (n=8831) underwent revascularization within 90 days, compared with 53% (n=13 316) of CA first patients (P<0.0001).

Conclusions: In this descriptive analysis, ST and invasive CA were common in older patients after PCI. Paradoxically, patients with higher risk features at baseline were less likely to undergo post-PCI testing. The revascularization yield was low on patients referred for ST after PCI, with only 7% [corrected] undergoing revascularization within 90 days.

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Figures

Figure 1a
Figure 1a. Linked dataset population description
This figure displays the linked dataset population (CathPCI and CMS), exclusions included.
Figure 1b
Figure 1b. Study population description
This figure displays initial patient cohort, through the final study population, exclusions included.
Figure 2
Figure 2. Cumulative incidence of stress test first, coronary angiography first, or death/myocardial infarction within 1 year and at least 60 days after index PCI
This figure displays the cumulative incidence of stress testing, coronary angiography or death/myocardial infarction in patients without a previous event, treating each type of event as a competing risk for the other types.
Figure 3
Figure 3. 30-day incremental incidence of stress test first, coronary angiography first, or death/myocardial infarction between 60 days and 1 year after index PCI
This figure displays the incremental incidence of stress testing, coronary angiography, or death/myocardial infarction per 30 day period in patients without a previous event, treating each type of event as a competing risk for the other types.
Figure 4
Figure 4. Hazard ratios associated with a risk of any test
Hazard ratios associated with a risk of stress test or coronary angiography compared to no test and risk of stress test first compared to coronary angiography first between 60 days and 12 months after PCI by baseline characteristics determined at time of index percutaneous coronary intervention.
See this image and copyright information in PMC

Comment in

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