CHANGES IN MORTALITY AFTER MYOCARDIAL REVASCULARIZATION IN THE ELDERLY - THE NATIONAL MEDICARE EXPERIENCE

Objective: To examine secular changes in the use and outcome of percut aneous transluminal coronary angioplasty and cardiac bypass graft surg ery in the elderly. Design: A retrospective cohort study based on a lo ngitudinal database created from the administrative files of Medicare. Setting: U.S. hospitals that perform myocardial revascularization pro cedures covered by Medicare. Patients: 225 915 consecutive patients wh o had angioplasty and 357 885 consecutive patients who had bypass surg ery from 1987 to 1990. Measurements: The rates of angioplasty and bypa ss surgery use; unadjusted 30-day and I-year mortality rates after rev ascularization; and adjusted odds ratios for mortality by year of proc edure for 1987 to 1990. Results: From 1987 to 1990, the rates of angio plasty and bypass surgery done in the elderly increased by 55% and 18% , respectively. During this period, 30-day unadjusted mortality rates after angioplasty and bypass surgery decreased by 25% (95% CI, 22% to 28%) and 12% (CI, 10% to 14%), and I-year mortality rates decreased by 10% (CI, 8% to 11%) and 8% (CI, 7% to 10%), respectively. After adjus tment for changes in patient characteristics, 30-day mortality rates a fter these procedures decreased by 37% (CI, 32% to 41%) and 18% (CI, 1 4% to 21%), and I-year mortality rates decreased by 22% (CI, 18% to 25 %) and 19% (CI, 16% to 21%), respectively. Conclusions: The use of car diac revascularization procedures in the elderly has steadily increase d. Patients who had revascularization are progressively older, have mo re coded comorbid conditions, and present with more acute diseases. Al though elderly patients have apparently higher risk profiles, mortalit y rates after angioplasty and bypass surgery in the elderly have decre ased, suggesting a national improvement in the outcomes of these inter ventions. Health policy decisions concerning revascularization procedu res in the elderly must consider these trends in improved outcome.