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Improving access to coronary angioplasty in hospitals without CABG surgery programs is risky

The decreased risk of complications following percutaneous coronary interventions (PCIs)—which include coronary angioplasty and other techniques for relieving coronary artery narrowing—has rekindled a decade-long debate on the safety of performing PCIs in hospitals without onsite coronary artery bypass graft (CABG) surgery programs, given that emergency CABG surgery may be needed following PCI. A recent study of Medicare beneficiaries suggests that PCI in the absence of on-site CABG surgery capability is associated with a higher risk of adverse outcomes.

In the study, which was supported in part by the Agency for Healthcare Research and Quality (HS10141), David E. Wennberg, M.D., M.P.H., of the Center for Outcomes Research and Evaluation, Maine Medical Center, and his colleagues compared in-hospital and 30-day deaths following PCI for 625,854 Medicare patients aged 65 and older at acute care facilities between 1999 and 2001. They identified hospitals with and without onsite CABG surgery based on Medicare claims data.

PCIs were performed by 178 hospitals without onsite CABG and 943 hospitals with onsite CABG. Patients at both types of hospitals had similar characteristics. Overall, combined in-hospital and 30-day post-procedure mortality was nearly twice as high in hospitals without onsite CABG surgery as those with it (6 percent vs. 3.3 percent). Those undergoing PCIs in hospitals with onsite CABG surgery were more likely to have a primary/rescue PCI (22 vs 5.6 percent), that is, same-day surgery for heart attack.

After accounting for baseline differences, mortality for patients with primary/rescue PCI was similar for both types of hospitals. However, for patients undergoing non-primary/rescue PCI, mortality was 38 percent higher in hospitals without onsite CABG surgery. This increase in mortality was primarily confined to hospitals performing a low volume of PCIs (50 or less a year) for Medicare patients.

For more information, see "Outcomes of percutaneous coronary interventions performed at centers without and with onsite coronary artery bypass graft surgery," by Dr. Wennberg, F. Lee Lucas, Ph.D., Andrea E. Siewers, M.P.H., and others in the October 27, 2004, Journal of the American Medical Association 292, pp. 1961-1968.

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