The consequences of under-use of coronary revascularization - Results of acohort study in Northern Italy

Aim To assess whether under-use of coronary artery bypass graft (CABG) or p ercutaneous transluminal coronary angioplasty (PTCA) affects patient outcom e. Patients and Methods A prospective observational study was performed follow ing up a cohort of patients, candidates for a revascularization procedure ( either CABG or PTCA) after an index angiogram. A total of 1258 patients, ca ndidates - according to explicit criteria for either CABG or PTCA entered t he study enrolled by 16 hospitals located in a Northern Italian region (Lom bardia). Information on demographic and clinical characteristics, type of c are received (i.e. CABG or PTCA performed Yes/No) and vital status was obta ined from revascularization laboratories, patients' hospital medical record s and local census offices of the town of patients' residence. The main out come measure was total unadjusted and adjusted mortality at a minimum follo w-up of 9 months after the index cardiac angiogram. Results Patients who received CABG or PTCA (n = 863) had lower mortality th an those who did not (n = 350) (4.8% vs 10.6%. P = 0.001). This held true a fter adjustment for relevant risk factors between the two groups such as ex tent of coronary artery disease, clinical symptoms, and cardiac surgical ri sk index (adjusted odds ratio = 0.48; 95% confidence intervals = 0.30-0.77) and after performing a survival analysis (adjusted hazard ratio = 0.31; 95 % confidence intervals = 0.19-0.50). Conclusions Failure to perform a revascularization procedure when it was in dicated led, in this study, to a significantly increased mortality showing that under-use of effective procedures may represent a significant quality of care problem even in areas where health care systems are well developed. Although the study was not specifically designed to identify determinants of under-use (i.e, reduced capacity leading to waiting lists, physicians' c ompetence or patients' refusal to undergo a recommended procedure) our data suggest that limited capacity could have been the most important reason. O ur findings also provide further evidence of the validity of the RAND metho d to assess the impact of under-use of coronary revascularization procedure s.