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Overuse of Coronary Artery Bypass Graft Surgery and Percutaneous Transluminal Coronary Angioplasty
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What is the problem and what is known about it so far?
Blockage of the arteries that supply blood to the heart (coronary heart disease) causes more deaths in the United States than any other condition. Many people with coronary heart disease undergo invasive procedures, such as coronary artery bypass graft surgery (CABG) or percutaneous transluminal coronary angioplasty (PTCA), to bypass or unblock clogged arteries. These procedures relieve chest pain and improve survival in some, but not all, patients with coronary heart disease. Research shows that white patients in the United States more commonly receive procedures for coronary heart disease than do African- American patients, even though coronary heart disease is more common in African- American patients than white patients. Some studies also show that CABG surgery and PTCA are “overused”; that is, they are performed even when they will probably not benefit patients. How much of the greater use of CABG surgery and PTCA among white patients in the United States is due to overuse is not known.
Why did the researchers do this particular study?
To find out whether the higher rates of CABG surgery and PTCA among white patients than among African-American patients are due to overuse in white patients.
Who was studied?
3960 men and women from 173 hospitals in five states. All were 65 to 75 years old.
How was the study done?
The researchers used routinely collected Medicare data (1991 to 1992) from five U.S. states to identify 103,035 older adults who had had heart catheterization to detect coronary heart disease. The researchers chose 3960 of these adults to study on the basis of sex, race, and income status. Medical records of these persons were reviewed to see who had had CABG surgery or PTCA. The researchers used standard criteria developed by experts to assess whether the procedures were appropriate, uncertain, or inappropriate. If a procedure was less likely to benefit a particular patient than to cause harm, it was called “inappropriate.”
What did the researchers find?
Twenty-nine percent of white patients and 17% of African-American patients had CABG surgery; 23% of white patients and 19% of African-American patients had PTCA. Rates of inappropriate CABG surgery were 10% for white patients and 10% for African-American patients. Rates of inappropriate PTCA were 15% for white patients and 9% for African-American patients. Rates of inappropriate procedure use across the five U.S. states ranged from 0% to 24%.
What were the limitations of the study?
Expert judgments about the appropriateness of the procedure were uncertain for about half of the people who had PTCA and 15% of the people who had CABG surgery.
What are the implications of the study?
Overuse of PTCA, but not CABG, is more common among white patients than African- American patients. Overuse varies by U.S. state; it may partly, but not totally, explain why white patients in general receive more surgical (CABG) procedures for coronary heart disease than do African-American patients.
Article and Author Information
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The summary below is from the full report titled “Racial Differences in Cardiac Revascularization Rates: Does ‘Overuse’ Explain Higher Rates among White Patients?” It is in the 4 September 2001 issue of Annals of Internal Medicine (volume 135, pages 328-337). The authors are EC Schneider, LL Leape, JS Weissman, RN Piana, C Gatsonis, and AM Epstein.
- Copyright ©2004 by the American College of Physicians
