Department of Medicine University of Calgary Alberta Canada.
Department of Community Health Sciences University of Calgary Alberta Canada.
J Am Heart Assoc. 2024 Sep 17;13(18):e035356. doi: 10.1161/JAHA.123.035356. Epub 2024 Sep 9.
Hospital- and physician-level variation for selection of percutaneous coronary intervention versus coronary artery bypass grafting (CABG) for patients with coronary artery disease has been associated with outcome differences. However, most studies excluded patients treated medically.
From 2010 to 2019, adults with 3-vessel or left main coronary artery disease at 3 hospitals (A, B, C) in Alberta, Canada, were categorized by treatment with medical therapy, percutaneous coronary intervention, or CABG. Multilevel regression models determined the proportion of variation in treatment attributable to patient, physician, and hospital factors, and survival models assessed outcomes including death and major adverse cardiovascular events over 5 years. Of 22 580 patients (mean age, 67 years; 80% men): 6677 (29%) received medical management, 9171 (41%) percutaneous coronary intervention, and 6732 (30%) CABG. Hospital factors accounted for 10.8% of treatment variation. In adjusted models (site A as reference), patients at sites B and C had 49% (95% CI, 44%-53%) and 43% (95% CI, 37%-49%) lower rates of medical therapy, respectively, and 31% (95% CI, 24%-38%) and 32% (95% CI, 24%-40%) lower rates of CABG. During 5.0 years median follow-up, 3287 (14.6%) patients died, with no intersite mortality differences. There were no between-site differences in acute coronary syndromes or stroke; patients at sites B and C had 24% lower risk (95% CI, 13%-34% and 11%-35%, respectively) of heart failure hospitalization.
Hospital-level variation in selection of percutaneous coronary intervention, CABG, or medical therapy for patients with complex coronary artery disease was not associated with differences in 5-year mortality rates. Research and quality improvement initiatives comparing revascularization practices should include medically managed patients.
医院和医生层面在选择经皮冠状动脉介入治疗（PCI）与冠状动脉旁路移植术（CABG）治疗冠心病患者方面的差异与预后差异有关。然而，大多数研究都排除了接受药物治疗的患者。
2010 年至 2019 年，在加拿大艾伯塔省的 3 家医院（A、B、C）中，患有 3 支血管或左主干冠状动脉疾病的成年人，根据药物治疗、PCI 或 CABG 进行分类。多水平回归模型确定了患者、医生和医院因素对治疗差异的归因比例，生存模型评估了 5 年内包括死亡和主要不良心血管事件在内的结局。在 22580 名患者（平均年龄 67 岁；80%为男性）中：6677 名（29%）接受药物治疗，9171 名（41%）接受 PCI，6732 名（30%）接受 CABG。医院因素占治疗差异的 10.8%。在调整后的模型中（以 A 医院为参照），B 医院和 C 医院的患者接受药物治疗的比例分别降低了 49%（95%可信区间，44%-53%）和 43%（95%可信区间，37%-49%），接受 CABG 的比例分别降低了 31%（95%可信区间，24%-38%）和 32%（95%可信区间，24%-40%）。在 5.0 年的中位随访期间，有 3287 名（14.6%）患者死亡，各站点间无死亡率差异。各站点间急性冠状动脉综合征或中风无差异；B 医院和 C 医院的心力衰竭住院风险分别降低了 24%（95%可信区间，13%-34%和 11%-35%）。
在选择 PCI、CABG 或药物治疗复杂冠状动脉疾病患者方面，医院层面的差异与 5 年死亡率无差异。比较血运重建实践的研究和质量改进计划应包括接受药物治疗的患者。
