Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.
Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota, USA.
Clin Cardiol. 2021 May;44(5):627-635. doi: 10.1002/clc.23583. Epub 2021 Mar 23.
Observational analyses comparing coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) among elderly or frail patients are likely biased by treatment selection. PCI is typically chosen for frail patients, while CABG is more common for patients with good recovery potential.
We hypothesized that skilled nursing facility (SNF) use after revascularization is a measure of relative frailty associated with outcomes following coronary revascularization.
We used a 20 percent sample of Medicare beneficiaries aged 65 years or older who received inpatient PCI or CABG between 2007-2014. Key explanatory variables were the revascularization strategy and SNF use after revascularization. We used Cox regression to evaluate death and repeat revascularization within one year and logistic regression to evaluate SNF use and 30-day readmissions/death.
CABG patients were 25.1 percentage points [95% confidence interval: 24.7, 25.5] more likely to use SNF following revascularization than inpatient PCI patients. SNF use was associated with a higher death rate (hazard ratio (HR): 3.19 [3.02, 3.37]) and a 16.2 percentage point (15.5, 16.9) increase in 30-day readmissions/death. Among patients with SNF use, CABG was associated with a decrease in 30-day readmissions/death compared to PCI.
While CABG was associated with higher rates of SNF use and 30-day readmission/death overall, CABG was associated with significantly lower rates of 30-day readmissions/death among patients with SNF use. The findings suggest that caution is needed in treatment selection for patients at high-risk for SNF use and that selection of inpatient PCI over CABG may be associated with frailty and worse outcomes for some patients.
在老年或体弱患者中比较冠状动脉旁路移植术（CABG）和经皮冠状动脉介入治疗（PCI）的观察性分析可能受到治疗选择的偏差。对于体弱患者，通常选择 PCI，而对于恢复潜力良好的患者，CABG 更为常见。
我们假设血管重建术后入住康复护理机构（SNF）是与冠状动脉血运重建后结局相关的相对虚弱的衡量标准。
我们使用了 Medicare 受益人的 20%样本，这些患者年龄在 65 岁或以上，在 2007-2014 年间接受过住院 PCI 或 CABG。关键解释变量是血管重建策略和血管重建后的 SNF 使用情况。我们使用 Cox 回归评估了一年内的死亡和再次血运重建，使用逻辑回归评估了 SNF 使用和 30 天再入院/死亡。
与住院 PCI 患者相比，CABG 患者在血管重建后入住 SNF 的可能性高 25.1 个百分点[95%置信区间：24.7，25.5]。SNF 使用与死亡率升高相关（危险比（HR）：3.19[3.02，3.37]），30 天再入院/死亡的发生率增加了 16.2 个百分点（15.5，16.9）。在使用 SNF 的患者中，与 PCI 相比，CABG 与 30 天再入院/死亡的发生率降低相关。
尽管 CABG 与更高的 SNF 使用和 30 天再入院/死亡总体相关，但在使用 SNF 的患者中，CABG 与 30 天再入院/死亡的发生率显著降低相关。这些发现表明，对于有入住 SNF 高风险的患者，在治疗选择时需要谨慎，并且与 CABG 相比，选择住院 PCI 可能与虚弱和一些患者的不良结局相关。
