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Previous Volume 335:1888-1896 December 19, 1996 Number 25 Next

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ABSTRACT

Background Wide geographic variation in the use of coronary angiography after myocardial infarction has been documented internationally and within the United States. An associated variation in clinical outcomes has not been consistently demonstrated.

Methods We assessed the risk of death from heart disease and of any heart disease event (death, reinfarction, or rehospitalization) over a follow-up period of one to four years in 6851 patients hospitalized with acute myocardial infarction at 16 Kaiser Permanente hospitals from 1990 through 1992. The percentage of patients who underwent angiography within three months after infarction ranged from 30 to 77 percent. We selected a subcohort of 1109 patients from three hospitals with higher rates of angiography and four with lower rates for a record review to assess the severity of infarction, the number of coexisting conditions, treatments received, and the appropriateness and necessity of angiography, using established criteria.

Results The rates of angiography were inversely related to the risk of death from heart disease (P = 0.03) and the risk of heart disease events (P<0.001) among the 16 hospitals after adjustment for age, sex, race, coexisting conditions, and the location of the infarction (subendocardial vs. transmural). In the subcohort, 440 patients met criteria indicating that angiography was necessary and 669 did not. Among the former, patients treated at hospitals with higher rates of angiography had a lower risk of death and of any heart disease event than those treated at hospitals with lower rates (hazard ratios, 0.67 and 0.72, respectively). Among the latter, the apparent benefits of being treated at hospitals with higher angiography rates were smaller (hazard ratios, 0.85 to 0.90 for death and any heart disease event, respectively).

Conclusions During the one to four years after myocardial infarction, patients treated at hospitals with higher rates of angiography had more favorable outcomes than those treated at hospitals with lower rates. This association was stronger among patients for whom published criteria indicated that angiography was necessary.

Source Information

From the Division of Research, Kaiser Permanente Medical Care Program (Northern California Region), Oakland (J.V.S., B.H.F., B.E.S., A.F.T.); the Division of Cardiology, Kaiser Permanente Medical Center, San Francisco (R.J.L.); the Department of Physiological Nursing (C.C.W., E.S.F.) and the Department of Medicine and Cardiovascular Research Institute (H.V.B.), University of California, San Francisco; and the Departments of Health Research and Policy and Medicine, Stanford University School of Medicine, Stanford, Calif. (M.A.H.).

Address reprint requests to Dr. Selby at the Division of Research, Kaiser Permanente Medical Care Program, 3505 Broadway, Oakland, CA 94611.

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