Trends in Characteristics and Outcomes of Hospital Inpatients Undergoing Coronary Revascularization in the United States, 2003-2016 | Acute Coronary Syndromes | JAMA Network Open | JAMA Network
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Figure 1.  Temporal Trend in the Annual Rate of Percutaneous and Surgical Coronary Revascularization per 100 000 US Adults
Temporal Trend in the Annual Rate of Percutaneous and Surgical Coronary Revascularization per 100 000 US Adults

Dashed line indicates the mean trend and solid line the year-to-year trend. CABG indicates coronary artery bypass grafting; PCI, percutaneous coronary intervention.

Figure 2.  Temporal Trend in the Risk-Adjusted In-Hospital Mortality With Coronary Revascularization Stratified by Clinical Indication
Temporal Trend in the Risk-Adjusted In-Hospital Mortality With Coronary Revascularization Stratified by Clinical Indication

Dashed line indicates the mean trend and solid line the year-to-year trend. AMI indicates acute myocardial infarction; CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention; NSTEMI, non–ST-segment elevation myocardial infarction; SIHD, stable ischemic heart disease; STEMI, ST-segment elevation myocardial infarction; and UA; unstable angina.

Table 1.  Temporal Changes in Baseline Characteristics of Patients Undergoing PCI
Temporal Changes in Baseline Characteristics of Patients Undergoing PCI
Table 2.  Temporal Changes in Baseline Characteristics of Patients Undergoing CABG
Temporal Changes in Baseline Characteristics of Patients Undergoing CABG
1.
Goetz  RH, Rohman  M, Haller  JD, Dee  R, Rosenak  SS.  Internal mammary-coronary artery anastomosis: a nonsuture method employing tantalum rings.   J Thorac Cardiovasc Surg. 1961;41:378-386.PubMedGoogle Scholar
2.
Bennett  J, Dubois  C.  Percutaneous coronary intervention, a historical perspective looking to the future.   J Thorac Dis. 2013;5(3):367-370.PubMedGoogle Scholar
3.
Melly  L, Torregrossa  G, Lee  T, Jansens  JL, Puskas  JD.  Fifty years of coronary artery bypass grafting.   J Thorac Dis. 2018;10(3):1960-1967. doi:10.21037/jtd.2018.02.43 PubMedGoogle ScholarCrossref
4.
Gogo  PB  Jr, Dauerman  HL, Mulgund  J,  et al; CRUSADE Investigators.  Changes in patterns of coronary revascularization strategies for patients with acute coronary syndromes (from the CRUSADE Quality Improvement Initiative).   Am J Cardiol. 2007;99(9):1222-1226. doi:10.1016/j.amjcard.2006.12.037 PubMedGoogle ScholarCrossref
5.
Gerber  Y, Rihal  CS, Sundt  TM  III,  et al.  Coronary revascularization in the community: a population-based study, 1990 to 2004.   J Am Coll Cardiol. 2007;50(13):1223-1229. doi:10.1016/j.jacc.2007.06.022 PubMedGoogle ScholarCrossref
6.
Mack  MJ, Brown  PP, Kugelmass  AD,  et al.  Current status and outcomes of coronary revascularization 1999 to 2002: 148,396 surgical and percutaneous procedures.   Ann Thorac Surg. 2004;77(3):761-766. doi:10.1016/j.athoracsur.2003.06.019 PubMedGoogle ScholarCrossref
7.
Lucas  FL, DeLorenzo  MA, Siewers  AE, Wennberg  DE.  Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993-2001.   Circulation. 2006;113(3):374-379. doi:10.1161/CIRCULATIONAHA.105.560433 PubMedGoogle ScholarCrossref
8.
Boden  WE, O’Rourke  RA, Teo  KK,  et al; COURAGE Trial Research Group.  Optimal medical therapy with or without PCI for stable coronary disease.   N Engl J Med. 2007;356(15):1503-1516. doi:10.1056/NEJMoa070829 PubMedGoogle ScholarCrossref
9.
Riley  RF, Don  CW, Powell  W, Maynard  C, Dean  LS.  Trends in coronary revascularization in the United States from 2001 to 2009: recent declines in percutaneous coronary intervention volumes.   Circ Cardiovasc Qual Outcomes. 2011;4(2):193-197. doi:10.1161/CIRCOUTCOMES.110.958744 PubMedGoogle ScholarCrossref
10.
Desai  NR, Bradley  SM, Parzynski  CS,  et al.  Appropriate use criteria for coronary revascularization and trends in utilization, patient selection, and appropriateness of percutaneous coronary intervention.   JAMA. 2015;314(19):2045-2053. doi:10.1001/jama.2015.13764 PubMedGoogle ScholarCrossref
11.
Raza  S, Deo  SV, Kalra  A,  et al.  Stability after initial decline in coronary revascularization rates in the United States.   Ann Thorac Surg. 2019;108(5):1404-1408. doi:10.1016/j.athoracsur.2019.03.080 PubMedGoogle ScholarCrossref
12.
von Elm  E, Altman  DG, Egger  M, Pocock  SJ, Gøtzsche  PC, Vandenbroucke  JP; STROBE Initiative.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.   PLoS Med. 2007;4(10):e296. doi:10.1371/journal.pmed.0040296 PubMedGoogle Scholar
13.
Alqahtani  F, Ziada  KM, Badhwar  V, Sandhu  G, Rihal  CS, Alkhouli  M.  Incidence, predictors, and outcomes of in-hospital percutaneous coronary intervention following coronary artery bypass grafting.   J Am Coll Cardiol. 2019;73(4):415-423. doi:10.1016/j.jacc.2018.10.071 PubMedGoogle ScholarCrossref
14.
Epstein  AJ, Polsky  D, Yang  F, Yang  L, Groeneveld  PW.  Coronary revascularization trends in the United States, 2001-2008.   JAMA. 2011;305(17):1769-1776. doi:10.1001/jama.2011.551 PubMedGoogle ScholarCrossref
15.
Doshi  R, Patel  N, Kalra  R,  et al.  Incidence and in-hospital outcomes of single-vessel coronary chronic total occlusion treated with percutaneous coronary intervention.   Int J Cardiol. 2018;269:61-66. doi:10.1016/j.ijcard.2018.07.075 PubMedGoogle ScholarCrossref
16.
Badheka  AO, Patel  NJ, Grover  P,  et al.  Impact of annual operator and institutional volume on percutaneous coronary intervention outcomes: a 5-year United States experience (2005-2009).   Circulation. 2014;130(16):1392-1406. doi:10.1161/CIRCULATIONAHA.114.009281 PubMedGoogle ScholarCrossref
17.
Alqahtani  F, Balla  S, AlHajji  M,  et al.  Temporal trends in the utilization and outcomes of percutaneous coronary interventions in patients with liver cirrhosis.   Catheter Cardiovasc Interv. 2019. doi:10.1002/ccd.28593 PubMedGoogle Scholar
18.
Alkhouli  M, Alqahtani  F, Tarabishy  A, Sandhu  G, Rihal  CS.  Incidence, predictors, and outcomes of acute ischemic stroke following percutaneous coronary intervention.   JACC Cardiovasc Interv. 2019;12(15):1497-1506. doi:10.1016/j.jcin.2019.04.015 PubMedGoogle ScholarCrossref
19.
Goel  K, Gupta  T, Gulati  R,  et al.  Temporal trends and outcomes of percutaneous coronary interventions in nonagenarians: a national perspective.   JACC Cardiovasc Interv. 2018;11(18):1872-1882. doi:10.1016/j.jcin.2018.06.026 PubMedGoogle ScholarCrossref
20.
Zou  G.  A modified Poisson regression approach to prospective studies with binary data.   Am J Epidemiol. 2004;159(7):702-706. doi:10.1093/aje/kwh090 PubMedGoogle ScholarCrossref
21.
Houchens  RL, Ross  D, Elixhauser  A. Using the HCUP National Inpatient Sample to Estimate Trends: 2015. HCUP Methods Series Report 2006-05. Rockville, MD: US Agency for Healthcare Research and Quality; January 4, 2016.
22.
Khera  R, Angraal  S, Couch  T,  et al.  Adherence to methodological standards in research using the National Inpatient Sample.   JAMA. 2017;318(20):2011-2018. doi:10.1001/jama.2017.17653 PubMedGoogle ScholarCrossref
23.
McNeely  C, Markwell  S, Vassileva  C.  Trends in patient characteristics and outcomes of coronary artery bypass grafting in the 2000 to 2012 Medicare population.   Ann Thorac Surg. 2016;102(1):132-138. doi:10.1016/j.athoracsur.2016.01.016 PubMedGoogle ScholarCrossref
24.
Hochman  JS, Reynolds  HR, Dzavík  V,  et al; Occluded Artery Trial Investigators.  Long-term effects of percutaneous coronary intervention of the totally occluded infarct-related artery in the subacute phase after myocardial infarction.   Circulation. 2011;124(21):2320-2328. doi:10.1161/CIRCULATIONAHA.111.041749 PubMedGoogle ScholarCrossref
25.
Frye  RL, August  P, Brooks  MM,  et al; BARI 2D Study Group.  A randomized trial of therapies for type 2 diabetes and coronary artery disease.   N Engl J Med. 2009;360(24):2503-2515. doi:10.1056/NEJMoa0805796 PubMedGoogle ScholarCrossref
26.
Windecker  S, Stortecky  S, Stefanini  GG,  et al.  Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis.   BMJ. 2014;348:g3859. doi:10.1136/bmj.g3859 PubMedGoogle ScholarCrossref
27.
Desai  R, Mirza  O, Sachdeva  R, Kumar  G.  Sex and racial disparities in fractional flow reserve-guided percutaneous coronary intervention utilization: a 5-year national experience.   Ann Transl Med. 2018;6(10):198. doi:10.21037/atm.2018.03.15 PubMedGoogle ScholarCrossref
28.
Song  Y, Liu  X, Zhu  X,  et al.  Increasing trend of diabetes combined with hypertension or hypercholesterolemia: NHANES data analysis 1999-2012.   Sci Rep. 2016;6:36093. doi:10.1038/srep36093 PubMedGoogle ScholarCrossref
29.
Centers for Disease Control and Prevention.  Long-term Trends in Diabetes. Atlanta, GA: Centers for Disease Control and Prevention; 2017.
30.
Vora  AN, Dai  D, Gurm  H,  et al.  Temporal trends in the risk profile of patients undergoing outpatient percutaneous coronary intervention: a report from the National Cardiovascular Data Registry’s CathPCI Registry.   Circ Cardiovasc Interv. 2016;9(3):e003070. doi:10.1161/CIRCINTERVENTIONS.115.003070 PubMedGoogle Scholar
31.
Iribarne  A, Goodney  PP, Flores  AM,  et al.  National trends and geographic variation in bilateral internal mammary artery use in the United States.   Ann Thorac Surg. 2017;104(6):1902-1907. doi:10.1016/j.athoracsur.2017.08.055 PubMedGoogle ScholarCrossref
32.
Chikwe  J, Lee  T, Itagaki  S, Adams  DH, Egorova  NN.  Long-term outcomes after off-pump versus on-pump coronary artery bypass grafting by experienced surgeons.   J Am Coll Cardiol. 2018;72(13):1478-1486. doi:10.1016/j.jacc.2018.07.029 PubMedGoogle ScholarCrossref
33.
Bakaeen  FG, Shroyer  AL, Gammie  JS,  et al.  Trends in use of off-pump coronary artery bypass grafting: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database.   J Thorac Cardiovasc Surg. 2014;148(3):856-3. doi:10.1016/j.jtcvs.2013.12.047PubMedGoogle ScholarCrossref
34.
Lamy  A, Devereaux  PJ, Prabhakaran  D,  et al; CORONARY Investigators.  Off-pump or on-pump coronary-artery bypass grafting at 30 days.   N Engl J Med. 2012;366(16):1489-1497. doi:10.1056/NEJMoa1200388 PubMedGoogle ScholarCrossref
35.
Fearon  WF, Nishi  T, De Bruyne  B,  et al; FAME 2 Trial Investigators.  Clinical outcomes and cost-effectiveness of fractional flow reserve-guided percutaneous coronary intervention in patients with stable coronary artery disease: three-year follow-up of the FAME 2 trial (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation).   Circulation. 2018;137(5):480-487. doi:10.1161/CIRCULATIONAHA.117.031907 PubMedGoogle ScholarCrossref
36.
Fearon  WF, Shilane  D, Pijls  NH,  et al; Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 2 (FAME 2) Investigators.  Cost-effectiveness of percutaneous coronary intervention in patients with stable coronary artery disease and abnormal fractional flow reserve.   Circulation. 2013;128(12):1335-1340. doi:10.1161/CIRCULATIONAHA.113.003059 PubMedGoogle ScholarCrossref
37.
Baschet  L, Bourguignon  S, Marque  S,  et al.  Cost-effectiveness of drug-eluting stents versus bare-metal stents in patients undergoing percutaneous coronary intervention.   Open Heart. 2016;3(2):e000445. doi:10.1136/openhrt-2016-000445 PubMedGoogle Scholar
38.
Squiers  JJ, Mack  MJ.  Coronary artery bypass grafting-fifty years of quality initiatives since Favaloro.   Ann Cardiothorac Surg. 2018;7(4):516-520. doi:10.21037/acs.2018.05.13 PubMedGoogle ScholarCrossref
39.
Kimmaliardjuk  DM, Toeg  H, Glineur  D, Sohmer  B, Ruel  M.  Operative mortality with coronary artery bypass graft: where do we stand in 2015?   Curr Opin Cardiol. 2015;30(6):611-618. doi:10.1097/HCO.0000000000000220 PubMedGoogle ScholarCrossref
40.
Romano  PS, Marcin  JP, Dai  JJ,  et al.  Impact of public reporting of coronary artery bypass graft surgery performance data on market share, mortality, and patient selection.   Med Care. 2011;49(12):1118-1125. doi:10.1097/MLR.0b013e3182358c78 PubMedGoogle ScholarCrossref
41.
Li  Z, Carlisle  DM, Marcin  JP,  et al.  Impact of public reporting on access to coronary artery bypass surgery: the California Outcomes Reporting Program.   Ann Thorac Surg. 2010;89(4):1131-1138. doi:10.1016/j.athoracsur.2009.12.073 PubMedGoogle ScholarCrossref
42.
Nallamothu  BK, Normand  SL, Wang  Y,  et al.  Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study.   Lancet. 2015;385(9973):1114-1122. doi:10.1016/S0140-6736(14)61932-2 PubMedGoogle ScholarCrossref
43.
Wayangankar  SA, Bangalore  S, McCoy  LA,  et al.  Temporal trends and outcomes of patients undergoing percutaneous coronary interventions for cardiogenic shock in the setting of acute myocardial infarction: a report from the CathPCI Registry.   JACC Cardiovasc Interv. 2016;9(4):341-351. doi:10.1016/j.jcin.2015.10.039 PubMedGoogle ScholarCrossref
44.
Fanaroff  AC, Zakroysky  P, Dai  D,  et al.  Outcomes of PCI in relation to procedural characteristics and operator volumes in the United States.   J Am Coll Cardiol. 2017;69(24):2913-2924. doi:10.1016/j.jacc.2017.04.032 PubMedGoogle ScholarCrossref
45.
Fanaroff  AC, Zakroysky  P, Wojdyla  D,  et al.  Relationship between operator volume and long-term outcomes after percutaneous coronary intervention.   Circulation. 2019;139(4):458-472. doi:10.1161/CIRCULATIONAHA.117.033325 PubMedGoogle ScholarCrossref
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    2 Comments for this article
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    Outpatient PCI missed by NIS?
    Vikas Bhalla MD, MSc, MBA ; Meenakshi A. Bhalla MD | University of Kentucky
    Dear Authors :
    I read the article by Alkhouli M (1) on Trends in Characteristics and Outcomes of Patients Undergoing Coronary Revascularization in the United States, 2003-2016 with much interest. First, I would like to congratulate the you for your excellent work. Secondly, I would request you to comment on the fact that National Inpatient Sample (NIS) does not account for outpatient percutaneous interventions in hospital catheterization laboratories (2). Given the significant increase in radial artery interventions and same day discharge in recent times (3), how would these outpatient interventions be accounted for? If not, is it possible that
    this decrease in annual PCIs could be partly representative of these contemporary technology and PCI transition to outpatient setting? For example, Alkhouli et al quote 466,820 PCIs in 2014 while Masoudi et al (4) reported significantly higher 667,424 PCIs from the NCDR CathPCI Program in the same year (Table 2 in manuscript). If this is true, and given that the outpatient elective PCIs did not need admissions and did not show up in NIS, can that change the characteristics of patients and mortality ratios as well?
    Also, recent CMS approval for Ambulatory Surgical Center based PCIs, and new technology like shock wave lithotripsy, this trend towards outpatient PCIs will likely continue. Hence, should we be taking in account these facts while interpreting NIS trends?
    Thanks.
    Sincerely,
    Vikas Bhalla MD, MSc, MBA ; Meenakshi A. Bhalla MD

    References
    (1) Alkhouli M, Alqahtani F, Kalra A, Gafoor S, Alhajji M, Alreshidan M, Holmes DR, Lerman A.Trends in Characteristics and Outcomes of Patients Undergoing Coronary Revascularization in the United States, 2003-2016. JAMA Netw Open. 2020 Feb 5;3(2):e1921326. doi: 10.1001/jamanetworkopen.2019.21326.
    (2) Epstein AJ, Polsky D, Yang F, Yang L, Groeneveld PW. Coronary revascularization trends in the United States, 2001-2008. JAMA. 2011;305(17):1769-1776. doi:10.1001/jama.2011.551
    (3) Amin AP, Crimmins-Reda P, Miller S, Rahn B, Caruso M, Pierce A, Dennis B, Pendegraft M, Sorensen K, Kurz HI, Lasala JM, Zajarias A, Bach RG, Kulkarni H, Singh J. Novel Patient-Centered Approach to Facilitate Same-Day Discharge in Patients Undergoing Elective Percutaneous Coronary Intervention. J Am Heart Assoc. 2018 Feb 15;7(4). pii: e005733. doi: 10.1161/JAHA.117.005733.
    (4) Masoudi FA, Ponirakis A, de Lemos JA, Jollis JG, Kremers M, Messenger JC, Moore JWM, Moussa I, Oetgen WJ, Varosy PD, Vincent RN, Wei J, Curtis JP, Roe MT, Spertus JA. Executive Summary: Trends in U.S. Cardiovascular Care: 2016 Report From 4 ACC National Cardiovascular Data Registries. J Am Coll Cardiol. 2017 Mar 21;69(11):1424-1426. doi: 10.1016/j.jacc.2016.12.004. Epub 2016 Dec 23. Review. PMID: 28025066
    CONFLICT OF INTEREST: None Reported
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    Reply: Outpatient PCI missed by NIS?
    Mohamad Alkhouli, MD | Mayo Clinic School of Medicine
    We thank Drs. Bhalla for their important observation related to our recent study published in the Journal. The study utilized the national inpatient sample (NIS) to assess temporal trends in coronary revascularization in the US between 2003 and 2016. As stated in the methods, the NIS includes hospital stays representative of 98% of admissions in the US. It does not, however, capture outpatient visits. Hence, procedures often performed in the outpatient settings may be underestimated in this registry. Nonetheless, the authors feel that this is unlikely to have impacted the overall results and conclusions of this study for the following reasons: (A) We studied 5 cohorts of patients undergoing coronary revascularization for various indications: CABG for AMI, CABG for non-AMI, PCI for STEMI, PCI for NSTEMI, and PCI for UA/SIHD. Out of these groups, the concerns about outpatient procedures only applies to the latter group (UA/SIHD), as patients in the other categories do not undergo revascularization in the outpatient setting. (B) Prior to 2014, outpatient PCIs were relatively infrequent (1-3). Our study spans 14 years, of which 11 were prior to the wider utilization of outpatient PCI. In addition, most of the decline in PCI volume occurred between before 2013 (-55% change). Therefore, we believe that the conclusions with regards to a temporal decline in PCI volume in the US over time remain valid. However, we agree that an assessment of the impact of outpatient PCI on the national PCI volume in recent years is warranted. (C) Similarly, the conclusions about the temporal change in PCI mortality overall should not be affected. The category of patients where PCI mortality is of a heightened concern are those with AMI. These patients (with STEMI or NSTEMI) do not undergo PCI in the outpatient settings, and their risk-adjusted mortality did not change overtime in our study. Also, mortality of PCI in the setting of stable coronary disease is <1%. Hence, the likelihood of a major change in the trend line due to the shifting of some elective PCI to the outpatient settings in the last couple years of the study is small. In addition, the changes in the characteristics of patients undergoing UA/SIHD in the NIS in the latest years of the study would have still been accounted for in our rigorous risk-adjustments.

    In summary, while it is possible that our analysis may have underestimated the national PCI volume of a sub-cohort of patients (those with UA/SIHD) in the latter part of the study, this would have not changed its main 2 conclusions: [1] a considerable decrease in coronary revascularization volume overall between 2003-2016; and [2] a decline in in-hospital mortality following CABG but not after PCI especially among patients presenting with AMI. Further studies are needed to elucidate reasons for these trends, and to identify effective strategies to optimize the outcomes of coronary revascularization procedures.

    References:
    1. Kumbhani DJ, Marso SP. Inpatient or Outpatient Status for Elective Percutaneous Coronary Intervention: Doctor, "You Gotta Let Me Know, Should I Stay or Should I Go?". Circ Cardiovasc Interv. 2016;9(3):e003699.
    2. Amin AP, Pinto D, House JA, et al. Association of Same-Day Discharge After Elective Percutaneous Coronary Intervention in the United States With Costs and Outcomes. JAMA Cardiol. 2018:1;3(11):1041-1049.
    3. Agarwal S, Thakkar B, Skelding KA, Blankenship JC. Trends and Outcomes After Same-Day Discharge After Percutaneous Coronary Interventions. Circ Cardiovasc Qual Outcomes. 2017;10(8) pii: e003936.
    CONFLICT OF INTEREST: None Reported
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    Original Investigation
    Cardiology
    February 14, 2020

    Trends in Characteristics and Outcomes of Hospital Inpatients Undergoing Coronary Revascularization in the United States, 2003-2016

    Author Affiliations
    • 1Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota
    • 2Division of Cardiology, Department of Medicine, University of Kentucky, Lexington
    • 3Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
    • 4Swedish Heart and Vascular Institute, Seattle, Washington
    • 5King Fahad Medical City, Riyadh, Saudi Arabia
    JAMA Netw Open. 2020;3(2):e1921326. doi:10.1001/jamanetworkopen.2019.21326
    Key Points español 中文 (chinese)

    Question  What are the contemporary trends in the characteristics and outcomes of patients undergoing coronary revascularization in hospitals in the United States?

    Findings  In this cohort study of patients undergoing percutaneous coronary intervention and coronary bypass grafting in hospitals in the United States from 2003 to 2016, risk-adjusted mortality temporally decreased significantly after coronary bypass grafting but not after percutaneous coronary intervention across all clinical indications.

    Meaning  This study revealed changes in the clinical profile of hospital inpatients referred for coronary revascularization and in the temporal trends of risk-adjusted mortality of percutaneous coronary intervention and coronary bypass grafting in the United States from 2003 to 2016.

    Abstract

    Importance  Data on the contemporary changes in risk profile and outcomes of patients undergoing percutaneous coronary intervention (PCI) or coronary bypass grafting (CABG) are limited.

    Objective  To assess the contemporary trends in the characteristics and outcomes of patients undergoing PCI or CABG in the United States.

    Design, Setting, and Participants  This retrospective cohort study used a national inpatient claims-based database to identify patients undergoing PCI or CABG from January 1, 2003, to December 31, 2016. Data analysis was performed from July 15 to October 4, 2019.

    Main Outcomes and Measures  Demographic characteristics, prevalence of risk factors, and clinical presentation divided into 3 eras (2003-2007, 2008-2012, and 2013-2016) and in-hospital mortality of PCI and CABG stratified by clinical indication.

    Results  A total of 12 062 081 revascularization hospitalizations were identified: 8 687 338 PCIs (72.0%; mean [SD] patient age, 66.0 [10.8] years; 66.2% male) and 3 374 743 CABGs (28.0%; mean [SD] patient age, 64.5 [12.4] years; 72.1% male). The annual PCI volume decreased from 366 to 180 per 100 000 US adults and the annual CABG volume from 159 to 82 per 100 000 US adults. A temporal increase in the proportions of older, male, nonwhite, and lower-income patients and in the prevalence of atherosclerotic and nonatherosclerotic risk factors was found in both groups. The percentage of revascularization for myocardial infarction (MI) increased in the PCI group (22.8% to 53.1%) and in the CABG group (19.5% to 28.2%). Risk-adjusted mortality increased slightly after PCI for ST-segment elevation MI (4.9% to 5.3%; P < .001 for trend) and unstable angina or stable ischemic heart disease (0.8% to 1.0%; P < .001 for trend) but remained stable after PCI for non–ST-segment elevation MI (1.6% to 1.6%; P = .18 for trend). Risk-adjusted CABG morality markedly decreased in patients with MI (5.6% to 3.4% for all CABG and 4.8% to 3.0% for isolated CABG) and in those without MI (2.8% to 1.7% for all CABG and 2.1% to 1.2% for isolated CABG) (P < .001 for all).

    Conclusions and Relevance  Significant changes were found in the characteristics of hospital inpatients undergoing PCI and CABG in the United States between 2003 and 2016. Risk-adjusted mortality decreased significantly after CABG but not after PCI across all clinical indications.

    Introduction

    Coronary artery revascularization has affected millions of patients with coronary artery disease (CAD) worldwide. Both surgical and percutaneous revascularization strategies have evolved from experimental stages to routine procedures that can safely tackle complex coronary anatomic features and high-risk patients.1-3 Several studies4-7 have documented a significant decrease in coronary artery bypass grafting (CABG) operations after the emergence of percutaneous coronary interventions (PCI) in the 1990s. However, the annual volumes of both PCI and CABG decreased significantly in more recent years possibly because of advances in medical therapy, the emergence of data questioning the benefit of PCI in stable CAD, and the increasing implementation of appropriate use criteria.8-11 Whether these temporal changes in procedural volume were associated with changes in the risk profiles of patients referred for percutaneous or surgical coronary revascularization and the outcomes of these procedures remain unknown. This study used a nationwide, representative sample hospital inpatients in the United States to assess the temporal changes in baseline characteristics of patients undergoing PCI or CABG and crude and risk-adjusted in-hospital mortality after PCI or CABG stratified by clinical indication.

    Methods
    Study Data

    We conducted a retrospective cohort study using the Nationwide Inpatient Sample (NIS) database to derive patient-relevant information from January 1, 2003, to December 31, 2016. Data analysis was performed from July 15 to October 4, 2019. The West Virginia University Institutional Review Board exempted the study from board approval and waived the requirement for informed consent because the NIS is a publicly available deidentified database. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.12

    The NIS is part of the Healthcare Cost and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality, and is the largest publicly available all-payer claims-based database in the United States. The database contains hospital inpatient stays derived from billing data submitted by hospitals to statewide data organizations across the United States. These data include clinical and resource use information typically available from discharge abstracts. Researchers and policy makers use the NIS to make national estimates of health care utilization, access, charges, quality, and outcomes. The NIS sampling frame includes data from 47 statewide data organizations, covering more than 97% of the US population. The annual sample encompasses approximately 8 million discharges, which represent 20% of inpatient hospitalizations across different hospital types and geographic regions. The national estimates of the entire US hospitalized population are calculated using a standardized sampling and weighting method provided by the HCUP. The NIS has been used extensively to assess national trends in the utilization, disparities, and outcomes of coronary artery interventions.13-19

    Study Population

    Patients aged 18 years or older who underwent PCI or CABG between 2003 and 2016 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes (eTable 1 in the Supplement). We further classified PCIs into those performed for ST-segment elevation myocardial infarction (STEMI), non–ST-segment elevation myocardial infarction (NSTEMI), or unstable angina or stable ischemic heart disease (UA-SIHD). Given the rarity of CABG performed in the context of STEMI, we classified CABG operations into 2 groups: CABG in the context of acute myocardial infarction (AMI) and CABG performed for UA-SIHD.

    Study Outcomes

    Our study investigated trends in clinical risk profile among hospital inpatients undergoing PCI and CABG divided into 3 eras (2003-2007, 2008-2012, and 2013-2016). These eras were selected to provide relatively equal periods and to illustrate the global and not the year-to-year change in baseline characteristics among patients undergoing coronary revascularization. The study also investigated trends in the crude and adjusted in-hospital mortality associated with PCI and CABG, stratified by clinical indication.

    Statistical Analysis

    Weighted data were used for all statistical analyses. Descriptive statistics are presented as numbers with percentages for categorical variables. Means (SDs) are used to report continuous measures. To evaluate changes in baseline characteristics by calendar year, we used the Mantel-Haenszel test of trend for categorical variables and linear regression for continuous variables. To assess whether in-hospital mortality improved over time, multivariable logistic regression models were constructed to estimate the odds ratios and 95% CIs. To directly estimate rate ratios, a modified Poisson regression approach was used that included a robust variance estimate in the models.20 Calendar year was included as a categorical variable, with 2003 as the reference year. All the multivariable regression models used in risk-adjusted estimates were fitted with generalized estimating equations to account for clustering of outcomes within hospitals. Adjusted risk ratios and P values for trend were determined with a model evaluating calendar year as a continuous variable. Variables included in the regression models included demographic characteristics (age, sex, and race/ethnicity), socioeconomic factors (primary expected payer and median household income), Elixhauser comorbidity index score, and clinically relevant comorbidities (eTable 2 in the Supplement). The trend weight files were merged onto the original NIS files by year and hospital identification number. For years before 2012, the trend weight was used to create national estimates for trend analysis. For 2012 and after, no trend weight was needed, and the regular discharge weight was used, consistent with the redesigned NIS trend analysis.21

    Statistical analysis was performed accounting for data changes in trend analysis and avoiding use of nonspecific secondary diagnosis codes to infer in-hospital events. Methodologic standards in research using the NIS were met as recommended.22 A 2-sided P < .05 was considered to be statistically significant. All statistical analyses were performed with SPSS software, version 24 (IBM Corp).

    Results

    A total of 12 062 081 revascularization hospitalizations were identified: 8 687 338 PCIs (72.0%; mean [SD] patient age, 66.0 [10.8] years; 66.2% male) and 3 374 743 CABGs (28.0%; mean [SD] patient age, 64.5 [12.4] years; 72.1% male). The annual PCI volume decreased from 777 780 in 2003 to 440 505 in 2016 (eTable 3 in the Supplement). This volume corresponded to a decrease in the PCI rate from 366 to 180 per 100 000 US adults between 2003 and 2016 (Figure 1). Similarly, the annual CABG volume decreased from 337 444 in 2003 to 201 840 in 2016, corresponding to a decrease in the CABG rate from 159 to 82 per 100 000 US adults between 2003 and 2016 (Figure 1 and eTable 3 in the Supplement). Significant temporal changes occurred in the demographic characteristics, socioeconomic status, prevalence of risk factors, and clinical presentations of patients undergoing PCI and CABG and in the characteristics of the procedures.

    In the PCI group, a temporal increase occurred in the proportions of older and male patients, nonwhite patients, and patients with lower socioeconomic status. There was also a significant increase in the prevalence of atherosclerotic and nonatherosclerotic risk factors (Table 1). The proportion of patients with an Elixhauser comorbidity index score of 3 or greater increased from 24.7% in 2003 to 2007 to 52.3% in 2012 to 2016. The proportion of women among all patients undergoing PCI decreased from 34.0% in 2003 to 2006 to 32.8% in 2012 to 2016 (P < .001). The proportion of women among all patients undergoing CABG decreased from 29.0% in 2003 to 2006 to 26.0% in 2012 to 2016 (P < .001). The percentage of PCI for AMI among all PCIs increased from 22.8% in 2003 to 2007 to 53.1% in 2012 to 2016. The characteristics of PCIs changed as well. Patients who underwent PCI between 2012 and 2016 (vs those who underwent PCI between 2003 and 2007) had fewer multivessel PCIs (16.2% vs 17.9%) and used bare metal stents less (15.5% vs 27.4%) but had more PCIs for chronic total occlusion (3.4% vs 0.1%) and cardiogenic shock (5.0% vs 1.8%) and had greater use of intravascular ultrasonography and/or fractional flow reserve (9.2% vs 2.5%) and circulatory support devices (4.6% vs 2.5%) (P < .001 for all).

    The CABG group also had a temporal increase in the proportion of male, elderly, and nonwhite patients and patients with lower socioeconomic status. Similar to what was observed in the PCI cohort, the prevalence of clinical risk factors increased significantly over time (Table 2). The proportion of patients with an Elixhauser comorbidity index score of 3 or greater increased from 29.8% in 2003 to 2007 to 52.2% in 2012 to 2016. The indications for CABG and surgical techniques also evolved over time. Compared with the 2003 to 2006 era, in 2012 to 2016, CABG was performed in a greater proportion of patients with AMI (28.2% vs 19.5%) and cardiogenic shock (6.1% vs 2.8%); however, these CABGs were more likely to be limited to 1 to 2 vessels (65.3% vs 55.6%), use arterial conduits (87% vs 82.2%), use double mammary conduits (3.7% vs 3.0%), or be isolated (86.9% vs 84.5%) but were less likely to use off-pump techniques (24.0% vs 19.3%) (P < .001 for all). Perioperative intra-aortic balloon pump use decreased from 9.7% to 8.9% (P < .001).

    In-hospital mortality after PCI increased between 2003 and 2016 (eTable 4 in the Supplement). However, after risk adjustment for patient- and hospital-level characteristics, in-hospital mortality only modestly increased after PCI for STEMI (4.9% to 5.3%; P < .001 for trend) or UA-SIHD (0.8% to 1.0%; P < .001) but remained stable after PCI for NSTEMI (1.6% to 1.6%; P = .18) (Figure 2A). In contrast, in-hospital mortality after isolated or combined CABG decreased significantly between 2003 and 2016 (eTable 5 in the Supplement). This temporal improvement in CABG mortality persisted after risk adjustment in both patients undergoing CABG in the context of AMI (5.6% to 3.4%; P < .001 for trend) or for UA-SIHD (2.8% to 1.7%; P < .001 for trend) (Figure 2B). Similar trends were observed when the analysis was limited to patients who underwent isolated CABG (Figure 2C and eTable 6 in the Supplement) or when we excluded patients who underwent both PCI and CABG during the same admission (eTable 7 in the Supplement). Length of stay after revascularization decreased across all groups, revascularization methods, and indications except among patients who underwent PCI for UA-SIHD (eTable 8 in the Supplement).

    Discussion

    This study documents 3 major findings. First, a decrease in the number of percutaneous and surgical coronary revascularization procedures conducted among hospital inpatients in the United States was found between 2003 and 2016. Second, significant changes were found in the demographic characteristics, socioeconomic status, risk profile, and clinical presentation of hospital inpatients undergoing coronary revascularization over time, as well as a significant change in the characteristics of the revascularization procedures. Third, a temporal decrease was found in in-hospital mortality after CABG but not after PCI across various indications.

    Several studies4-6,9,11,14,23 have found a decrease in coronary revascularization procedures in the United States in the past 2 decades. However, most of these studies4-6,9,11,14,23 were not contemporaneous, included only certain subsets of patients (eg, patients with Medicare insurance or AMI), or examined trends of surgical or percutaneous revascularization procedures. Although our primary objective was to assess the temporal changes among hospital inpatient risk profiles, procedural characteristics, and procedural mortality, the current study, to our knowledge, provides the most up-to-date nationwide analysis of the annual trends in coronary interventions conducted in hospitals. We documented a 40% decrease in CABG volume and a 43% decrease in PCI volume between 2003 and 2016. However, these downward trends appeared to stabilize at approximately 200 000 CABG procedures annually and 450 000 PCIs annually, with CABG volume reaching a steady level earlier than PCI volume (2010 vs 2014). Albeit speculative, reasons for these downward trends in the earlier years of our study may include the change in the management of stable CAD after the publication of landmark clinical trials reporting the effectiveness of medical management of stable CAD,8,24,25 the implementation of appropriate use criteria, and the improved efficacy of CAD preventive measures.8,10,14,26 The increasing proportion of patients with AMI among all patients undergoing PCI (22.8% to 53.1%) and CABG (19.6% to 28.2%) over time further supports this notion.

    This study also found a temporal change in the demographic characteristics, socioeconomic status, and clinical risk profiles of hospital inpatients undergoing PCI or CABG and an evolution of the characteristics of these procedures. There was a modest increase in the number of elderly patients undergoing PCI or CABG but a more notable increase in the proportion of racial/ethnic minority patients and those with lower household income over time. Although this finding may reflect a change in the total population demographic characteristics and socioeconomic status during the same period, it may also partially reflect better penetration of coronary interventions to underserved populations.27 With regard to sex-related disparities in revascularization, not only did women remained underrepresented (approximately one-third overall) but also their proportion among all patients undergoing revascularization continued to decrease in both the CABG cohort (29.0% in 2003-2006 to 26.0% in 2012-2016, P < .001) and the PCI cohort (34.0% in 2003-2006 to 32.8% in 2012-2016, P < .001). Reasons for this disparity are likely multifaceted and deserve further investigations.

    There was a marked increase in the prevalence of clinical risk factors among hospital inpatients undergoing revascularization over time, which was reflected by the doubling of the proportion of patients with an Elixhauser comorbidity index score of 3 or greater between 2003 and 2016 in both the PCI and the CABG cohorts. This increase was global for atherosclerotic risk factors (eg, hypertension, hyperlipidemia, and diabetes), nonatherosclerotic risk factors (eg, lung, renal, and liver disease), and concomitant noncoronary atherosclerosis (eg, carotid stenosis and vascular disease). This finding may represent an increase in the prevalence of certain risk factors in the total US population,28,29 the tendency to offer revascularization to sicker populations,30 the shift in risk resulting from performing fewer revascularization procedures in patients with stable CAD, or the database included in this study, which does not include PCIs conducted in outpatient settings, or a mixture of these factors. These findings have important implications for prerevascularization risk assessment and postrevascularization medical management. For example, the increasing prevalence of atrial fibrillation and anemia among hospital inpatients undergoing PCI may pose a challenge for a post-PCI antithrombotic and antiplatelet medical regimen.

    The changes in hospital inpatient presentation and clinical risk profile were also accompanied by changes in coronary revascularization techniques over time. In the PCI cohort, there was an increasing uptake of intravascular ultrasonography and fractional flow reserve measurement and a downward trend in the use of bare metal stents. There was also an increasing representation of higher-risk patients (eg, cardiogenic shock and chronic total occlusion) but fewer multivessel PCIs. In the CABG cohort, there were fewer multivessel (>2) CABGs and off-pump CABGs but greater use of arterial conduits over time. These trends likely reflect the effect of the emerging data that suggest the incremental benefit of certain techniques or devices (eg, fractional flow reserve, drug-eluting stents, and arterial conduits) and the limited value of others (eg, off-pump bypass).31-38

    We hypothesized that the temporal decrease in PCI and CABG volume, as well as the accompanying changes in hospital inpatient risk profile and procedural characteristics, might have been associated with a change in procedural mortality over time. We thus evaluated crude and risk-adjusted rates of in-hospital mortality of both procedures stratified by indication. We found that crude and risk-adjusted CABG mortality decreased significantly over time despite the substantial decrease in annual volume and the increasing prevalence of key comorbidities. Reasons for this trend may include changes in surgical techniques, the wider adoption of quality improvement, the changes in case mix and patient selection in light of the advances in PCI techniques, and public reporting of surgical outcomes, as well as the limitations of the NIS database.39-41

    Contemporary data on the trends in PCI mortality are limited to subanalysis of specific PCI indications or certain subgroups of hospital inpatients. In a large study42 from the National Cardiovascular Data Registry CathPCI Registry, risk-adjusted in-hospital mortality of primary PCI for STEMI increased from 4.7% in 2005 to 5.3% in 2011 (P = .06). In another analysis43 from the same CathPCI registry, in-hospital mortality after PCI for cardiogenic shock increased over time. Goel et al19 found that in-hospital mortality after PCI in nonagenarians remained stable between 2003 and 2014 in the context of STEMI or NSTEMI but increased in the context of UA-SIHD.

    To our knowledge, our study provides the largest contemporary analysis of the temporal trends of PCI mortality among hospital inpatients overall. In this analysis, we found that in-hospital mortality after PCI did not improve over time. These findings may seem counterintuitive because of the advances in PCI tools, technique, and quality (eg, drug-eluting stents, radial access, mechanical circulatory support, and door-to-balloon time); however, other factors could have offset the assumed mortality benefits of these tools and techniques (eg, decreased operator experience and inadequate adjustment for patient risk in our study’s database). These assumptions deserve further elaboration. The association between operator volume and outcomes after coronary revascularization has been both well-established historically and reconfirmed in contemporary analyses.13,44,45 Although the decrease in operator experience because of the decreasing volume of revascularization procedures applies to both CABG and PCI, we speculate that its association with outcomes might be greater with PCI because of the larger number of PCI operators. Similarly, the lack of granular anatomic, laboratory, and procedural data in the NIS may have influenced the robustness of our risk adjustment. Although this lack of data applies to both the PCI and CABG groups, it is possible that the addition of such data to the logistic regression models could have affected the PCI group more than the CABG group. For example, the complexity of coronary lesions (eg, bifurcation and calcification) may affect PCI outcomes more than CABG outcomes. Nonetheless, in light of these data, more studies are needed to identify effective strategies to further optimize PCI outcomes.

    Limitations

    This study has limitations. First, the NIS is an administrative database that collects data for billing purposes. Thus, it is subject to undercoding, overcoding, or erroneous coding. However, coding of major procedures is the main method of obtaining reimbursement, and thus systematic inaccuracy in coding for PCI and CABG is unlikely. In addition, the NIS database has been used extensively to examine PCI and CABG trends and outcomes. Epstein et al14 validated the accuracy of the national estimation of annual volume with NIS by reporting a mean difference of 0.2% in quarterly PCI counts between Medicare claims and the NIS. Second, angiographic findings, laboratory data, characteristics of the PCI or CABG culprit vessel(s), access site, and perioperative medications are not available in NIS. Thus, the association of these unmeasured confounders with postrevascularization outcomes cannot be assessed. Third, the NIS allows detailed assessment of in-hospital outcomes but does not track patients after discharge or account for procedures conducted among outpatients. Therefore, long-term outcomes after PCI or CABG could not be investigated with this database. Despite these limitations, the NIS affords the unique opportunity to comprehensively assess the national trends in the utilization and outcomes of both percutaneous and surgical revascularization procedures in the United States during a 14-year period.

    Conclusions

    There were considerable changes in the demographic characteristics, risk profile, and clinical presentation of patients undergoing PCI and CABG in hospitals that accompanied the substantial decrease in the annual volume of both procedures in the United states between 2003 and 2016. Risk-adjusted in-hospital mortality decreased over time after CABG but not after PCI across various clinical indications.

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    Article Information

    Accepted for Publication: December 17, 2019.

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Alkhouli M et al. JAMA Network Open.

    Published: February 14, 2020. doi:10.1001/jamanetworkopen.2019.21326

    Correction: This article was corrected on April 28, 2020, to specify that the study database included only hospital inpatients.

    Corresponding Author: Mohamad Alkhouli, MD, Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (alkhouli.mohamad@mayo.edu).

    Author Contributions: Drs Alkhouli and Alqahtani had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Alkhouli, Alqahtani, Gafoor, Lerman.

    Acquisition, analysis, or interpretation of data: Alqahtani, Kalra, Gafoor, Alhajji, Alreshidan, Holmes, Lerman.

    Drafting of the manuscript: Alkhouli, Alqahtani, Alhajji, Alreshidan, Lerman.

    Critical revision of the manuscript for important intellectual content: Alkhouli, Alqahtani, Kalra, Gafoor, Holmes.

    Statistical analysis: Alqahtani, Alhajji.

    Administrative, technical, or material support: Alkhouli, Alhajji, Holmes.

    Supervision: Alkhouli, Kalra, Lerman.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Goetz  RH, Rohman  M, Haller  JD, Dee  R, Rosenak  SS.  Internal mammary-coronary artery anastomosis: a nonsuture method employing tantalum rings.   J Thorac Cardiovasc Surg. 1961;41:378-386.PubMedGoogle Scholar
    2.
    Bennett  J, Dubois  C.  Percutaneous coronary intervention, a historical perspective looking to the future.   J Thorac Dis. 2013;5(3):367-370.PubMedGoogle Scholar
    3.
    Melly  L, Torregrossa  G, Lee  T, Jansens  JL, Puskas  JD.  Fifty years of coronary artery bypass grafting.   J Thorac Dis. 2018;10(3):1960-1967. doi:10.21037/jtd.2018.02.43 PubMedGoogle ScholarCrossref
    4.
    Gogo  PB  Jr, Dauerman  HL, Mulgund  J,  et al; CRUSADE Investigators.  Changes in patterns of coronary revascularization strategies for patients with acute coronary syndromes (from the CRUSADE Quality Improvement Initiative).   Am J Cardiol. 2007;99(9):1222-1226. doi:10.1016/j.amjcard.2006.12.037 PubMedGoogle ScholarCrossref
    5.
    Gerber  Y, Rihal  CS, Sundt  TM  III,  et al.  Coronary revascularization in the community: a population-based study, 1990 to 2004.   J Am Coll Cardiol. 2007;50(13):1223-1229. doi:10.1016/j.jacc.2007.06.022 PubMedGoogle ScholarCrossref
    6.
    Mack  MJ, Brown  PP, Kugelmass  AD,  et al.  Current status and outcomes of coronary revascularization 1999 to 2002: 148,396 surgical and percutaneous procedures.   Ann Thorac Surg. 2004;77(3):761-766. doi:10.1016/j.athoracsur.2003.06.019 PubMedGoogle ScholarCrossref
    7.
    Lucas  FL, DeLorenzo  MA, Siewers  AE, Wennberg  DE.  Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993-2001.   Circulation. 2006;113(3):374-379. doi:10.1161/CIRCULATIONAHA.105.560433 PubMedGoogle ScholarCrossref
    8.
    Boden  WE, O’Rourke  RA, Teo  KK,  et al; COURAGE Trial Research Group.  Optimal medical therapy with or without PCI for stable coronary disease.   N Engl J Med. 2007;356(15):1503-1516. doi:10.1056/NEJMoa070829 PubMedGoogle ScholarCrossref
    9.
    Riley  RF, Don  CW, Powell  W, Maynard  C, Dean  LS.  Trends in coronary revascularization in the United States from 2001 to 2009: recent declines in percutaneous coronary intervention volumes.   Circ Cardiovasc Qual Outcomes. 2011;4(2):193-197. doi:10.1161/CIRCOUTCOMES.110.958744 PubMedGoogle ScholarCrossref
    10.
    Desai  NR, Bradley  SM, Parzynski  CS,  et al.  Appropriate use criteria for coronary revascularization and trends in utilization, patient selection, and appropriateness of percutaneous coronary intervention.   JAMA. 2015;314(19):2045-2053. doi:10.1001/jama.2015.13764 PubMedGoogle ScholarCrossref
    11.
    Raza  S, Deo  SV, Kalra  A,  et al.  Stability after initial decline in coronary revascularization rates in the United States.   Ann Thorac Surg. 2019;108(5):1404-1408. doi:10.1016/j.athoracsur.2019.03.080 PubMedGoogle ScholarCrossref
    12.
    von Elm  E, Altman  DG, Egger  M, Pocock  SJ, Gøtzsche  PC, Vandenbroucke  JP; STROBE Initiative.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.   PLoS Med. 2007;4(10):e296. doi:10.1371/journal.pmed.0040296 PubMedGoogle Scholar
    13.
    Alqahtani  F, Ziada  KM, Badhwar  V, Sandhu  G, Rihal  CS, Alkhouli  M.  Incidence, predictors, and outcomes of in-hospital percutaneous coronary intervention following coronary artery bypass grafting.   J Am Coll Cardiol. 2019;73(4):415-423. doi:10.1016/j.jacc.2018.10.071 PubMedGoogle ScholarCrossref
    14.
    Epstein  AJ, Polsky  D, Yang  F, Yang  L, Groeneveld  PW.  Coronary revascularization trends in the United States, 2001-2008.   JAMA. 2011;305(17):1769-1776. doi:10.1001/jama.2011.551 PubMedGoogle ScholarCrossref
    15.
    Doshi  R, Patel  N, Kalra  R,  et al.  Incidence and in-hospital outcomes of single-vessel coronary chronic total occlusion treated with percutaneous coronary intervention.   Int J Cardiol. 2018;269:61-66. doi:10.1016/j.ijcard.2018.07.075 PubMedGoogle ScholarCrossref
    16.
    Badheka  AO, Patel  NJ, Grover  P,  et al.  Impact of annual operator and institutional volume on percutaneous coronary intervention outcomes: a 5-year United States experience (2005-2009).   Circulation. 2014;130(16):1392-1406. doi:10.1161/CIRCULATIONAHA.114.009281 PubMedGoogle ScholarCrossref
    17.
    Alqahtani  F, Balla  S, AlHajji  M,  et al.  Temporal trends in the utilization and outcomes of percutaneous coronary interventions in patients with liver cirrhosis.   Catheter Cardiovasc Interv. 2019. doi:10.1002/ccd.28593 PubMedGoogle Scholar
    18.
    Alkhouli  M, Alqahtani  F, Tarabishy  A, Sandhu  G, Rihal  CS.  Incidence, predictors, and outcomes of acute ischemic stroke following percutaneous coronary intervention.   JACC Cardiovasc Interv. 2019;12(15):1497-1506. doi:10.1016/j.jcin.2019.04.015 PubMedGoogle ScholarCrossref
    19.
    Goel  K, Gupta  T, Gulati  R,  et al.  Temporal trends and outcomes of percutaneous coronary interventions in nonagenarians: a national perspective.   JACC Cardiovasc Interv. 2018;11(18):1872-1882. doi:10.1016/j.jcin.2018.06.026 PubMedGoogle ScholarCrossref
    20.
    Zou  G.  A modified Poisson regression approach to prospective studies with binary data.   Am J Epidemiol. 2004;159(7):702-706. doi:10.1093/aje/kwh090 PubMedGoogle ScholarCrossref
    21.
    Houchens  RL, Ross  D, Elixhauser  A. Using the HCUP National Inpatient Sample to Estimate Trends: 2015. HCUP Methods Series Report 2006-05. Rockville, MD: US Agency for Healthcare Research and Quality; January 4, 2016.
    22.
    Khera  R, Angraal  S, Couch  T,  et al.  Adherence to methodological standards in research using the National Inpatient Sample.   JAMA. 2017;318(20):2011-2018. doi:10.1001/jama.2017.17653 PubMedGoogle ScholarCrossref
    23.
    McNeely  C, Markwell  S, Vassileva  C.  Trends in patient characteristics and outcomes of coronary artery bypass grafting in the 2000 to 2012 Medicare population.   Ann Thorac Surg. 2016;102(1):132-138. doi:10.1016/j.athoracsur.2016.01.016 PubMedGoogle ScholarCrossref
    24.
    Hochman  JS, Reynolds  HR, Dzavík  V,  et al; Occluded Artery Trial Investigators.  Long-term effects of percutaneous coronary intervention of the totally occluded infarct-related artery in the subacute phase after myocardial infarction.   Circulation. 2011;124(21):2320-2328. doi:10.1161/CIRCULATIONAHA.111.041749 PubMedGoogle ScholarCrossref
    25.
    Frye  RL, August  P, Brooks  MM,  et al; BARI 2D Study Group.  A randomized trial of therapies for type 2 diabetes and coronary artery disease.   N Engl J Med. 2009;360(24):2503-2515. doi:10.1056/NEJMoa0805796 PubMedGoogle ScholarCrossref
    26.
    Windecker  S, Stortecky  S, Stefanini  GG,  et al.  Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis.   BMJ. 2014;348:g3859. doi:10.1136/bmj.g3859 PubMedGoogle ScholarCrossref
    27.
    Desai  R, Mirza  O, Sachdeva  R, Kumar  G.  Sex and racial disparities in fractional flow reserve-guided percutaneous coronary intervention utilization: a 5-year national experience.   Ann Transl Med. 2018;6(10):198. doi:10.21037/atm.2018.03.15 PubMedGoogle ScholarCrossref
    28.
    Song  Y, Liu  X, Zhu  X,  et al.  Increasing trend of diabetes combined with hypertension or hypercholesterolemia: NHANES data analysis 1999-2012.   Sci Rep. 2016;6:36093. doi:10.1038/srep36093 PubMedGoogle ScholarCrossref
    29.
    Centers for Disease Control and Prevention.  Long-term Trends in Diabetes. Atlanta, GA: Centers for Disease Control and Prevention; 2017.
    30.
    Vora  AN, Dai  D, Gurm  H,  et al.  Temporal trends in the risk profile of patients undergoing outpatient percutaneous coronary intervention: a report from the National Cardiovascular Data Registry’s CathPCI Registry.   Circ Cardiovasc Interv. 2016;9(3):e003070. doi:10.1161/CIRCINTERVENTIONS.115.003070 PubMedGoogle Scholar
    31.
    Iribarne  A, Goodney  PP, Flores  AM,  et al.  National trends and geographic variation in bilateral internal mammary artery use in the United States.   Ann Thorac Surg. 2017;104(6):1902-1907. doi:10.1016/j.athoracsur.2017.08.055 PubMedGoogle ScholarCrossref
    32.
    Chikwe  J, Lee  T, Itagaki  S, Adams  DH, Egorova  NN.  Long-term outcomes after off-pump versus on-pump coronary artery bypass grafting by experienced surgeons.   J Am Coll Cardiol. 2018;72(13):1478-1486. doi:10.1016/j.jacc.2018.07.029 PubMedGoogle ScholarCrossref
    33.
    Bakaeen  FG, Shroyer  AL, Gammie  JS,  et al.  Trends in use of off-pump coronary artery bypass grafting: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database.   J Thorac Cardiovasc Surg. 2014;148(3):856-3. doi:10.1016/j.jtcvs.2013.12.047PubMedGoogle ScholarCrossref
    34.
    Lamy  A, Devereaux  PJ, Prabhakaran  D,  et al; CORONARY Investigators.  Off-pump or on-pump coronary-artery bypass grafting at 30 days.   N Engl J Med. 2012;366(16):1489-1497. doi:10.1056/NEJMoa1200388 PubMedGoogle ScholarCrossref
    35.
    Fearon  WF, Nishi  T, De Bruyne  B,  et al; FAME 2 Trial Investigators.  Clinical outcomes and cost-effectiveness of fractional flow reserve-guided percutaneous coronary intervention in patients with stable coronary artery disease: three-year follow-up of the FAME 2 trial (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation).   Circulation. 2018;137(5):480-487. doi:10.1161/CIRCULATIONAHA.117.031907 PubMedGoogle ScholarCrossref
    36.
    Fearon  WF, Shilane  D, Pijls  NH,  et al; Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 2 (FAME 2) Investigators.  Cost-effectiveness of percutaneous coronary intervention in patients with stable coronary artery disease and abnormal fractional flow reserve.   Circulation. 2013;128(12):1335-1340. doi:10.1161/CIRCULATIONAHA.113.003059 PubMedGoogle ScholarCrossref
    37.
    Baschet  L, Bourguignon  S, Marque  S,  et al.  Cost-effectiveness of drug-eluting stents versus bare-metal stents in patients undergoing percutaneous coronary intervention.   Open Heart. 2016;3(2):e000445. doi:10.1136/openhrt-2016-000445 PubMedGoogle Scholar
    38.
    Squiers  JJ, Mack  MJ.  Coronary artery bypass grafting-fifty years of quality initiatives since Favaloro.   Ann Cardiothorac Surg. 2018;7(4):516-520. doi:10.21037/acs.2018.05.13 PubMedGoogle ScholarCrossref
    39.
    Kimmaliardjuk  DM, Toeg  H, Glineur  D, Sohmer  B, Ruel  M.  Operative mortality with coronary artery bypass graft: where do we stand in 2015?   Curr Opin Cardiol. 2015;30(6):611-618. doi:10.1097/HCO.0000000000000220 PubMedGoogle ScholarCrossref
    40.
    Romano  PS, Marcin  JP, Dai  JJ,  et al.  Impact of public reporting of coronary artery bypass graft surgery performance data on market share, mortality, and patient selection.   Med Care. 2011;49(12):1118-1125. doi:10.1097/MLR.0b013e3182358c78 PubMedGoogle ScholarCrossref
    41.
    Li  Z, Carlisle  DM, Marcin  JP,  et al.  Impact of public reporting on access to coronary artery bypass surgery: the California Outcomes Reporting Program.   Ann Thorac Surg. 2010;89(4):1131-1138. doi:10.1016/j.athoracsur.2009.12.073 PubMedGoogle ScholarCrossref
    42.
    Nallamothu  BK, Normand  SL, Wang  Y,  et al.  Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study.   Lancet. 2015;385(9973):1114-1122. doi:10.1016/S0140-6736(14)61932-2 PubMedGoogle ScholarCrossref
    43.
    Wayangankar  SA, Bangalore  S, McCoy  LA,  et al.  Temporal trends and outcomes of patients undergoing percutaneous coronary interventions for cardiogenic shock in the setting of acute myocardial infarction: a report from the CathPCI Registry.   JACC Cardiovasc Interv. 2016;9(4):341-351. doi:10.1016/j.jcin.2015.10.039 PubMedGoogle ScholarCrossref
    44.
    Fanaroff  AC, Zakroysky  P, Dai  D,  et al.  Outcomes of PCI in relation to procedural characteristics and operator volumes in the United States.   J Am Coll Cardiol. 2017;69(24):2913-2924. doi:10.1016/j.jacc.2017.04.032 PubMedGoogle ScholarCrossref
    45.
    Fanaroff  AC, Zakroysky  P, Wojdyla  D,  et al.  Relationship between operator volume and long-term outcomes after percutaneous coronary intervention.   Circulation. 2019;139(4):458-472. doi:10.1161/CIRCULATIONAHA.117.033325 PubMedGoogle ScholarCrossref
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