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Previous Volume 333:573-578 August 31, 1995 Number 9 Next

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ABSTRACT

Background There are large geographic differences in the frequency with which coronary angiography and revascularization are performed. We attempted to assess whether differences in case mix or in the treatment of specific groups of patients may explain this variability. We also assessed the consequences of various patterns of treatment.

Methods We studied patients covered by Medicare who were 65 to 79 years of age and were admitted to 478 hospitals with acute myocardial infarctions during 1990 in New York (1852 patients), where the rate of use of cardiac procedures is low, and in Texas (1837 patients), where the rate of use of such procedures is high. We compared the patterns of treatment of clinically similar groups of patients in the two states. We also compared mortality rates and measures of the health-related quality of life.

Results Coronary angiography was performed more often in Texas than in New York (45 percent vs. 30 percent, P<0.001). The frequency of use in Texas was significantly higher than that in New York for all the clinical subgroups of patients analyzed except those at greatest risk for reinfarction. Over a two-year period, the adjusted likelihood of death was lower in New York than in Texas (hazard ratio, 0.87; 95 percent confidence interval, 0.78 to 0.98). Patients from Texas were 41 percent more likely to report angina (P = 0.002) and 62 percent more likely to say they could not perform activities requiring energy expenditure of 5 or more metabolic equivalents than patients from New York approximately two years after infarction (P<0.001).

Conclusions Physicians in Texas were more likely to perform angiography than physicians in New York for patients whose conditions allowed more discretion in the use of cardiac procedures. On average, there appears to be no advantage with respect to mortality or health-related quality of life to performing the procedures at the higher rate used in Texas.

Source Information

From the Department of Health Care Policy, Harvard Medical School (E.G., C.L.P., B.J.M., P.D.C.); the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (P.J.H.); and the Division of General Medicine, Section on Health Services and Policy Research, Department of Medicine, Brigham and Women's Hospital (J.Z.A.) — all in Boston.

Address reprint requests to Dr. Guadagnoli at the Department of Health Care Policy, Harvard Medical School, 25 Shattuck St., Parcel B — 1st Fl., Boston, MA 02115.

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