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Cited by 262Coronary Interventions and DiagnosticsCardiac Imaging and DiagnosticsCardiac and Coronary Surgery Techniques

Underuse of coronary revascularization procedures in patients considered appropriate candidates for revascularization

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Hemingway, Harry, Crook, Angela M., Feder, Gene, Banerjee, Shrilla, Dawson, J. Rex, Magee, Patrick, Philpott, Sue, Sanders, Julie +2 more·2001·New England Journal of Medicine
DOI 10.1056/nejm200103013440906
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Abstract

BACKGROUND: Ratings by an expert panel of the appropriateness of treatments may offer better guidance for clinical practice than the variable decisions of individual clinicians, yet there have been no prospective studies of clinical outcomes. We compared the clinical outcomes of patients treated medically after angiography with those of patients who underwent revascularization, within groups defined by ratings of the degree of appropriateness of revascularization in varying clinical circumstances. METHODS: This was a prospective study of consecutive patients undergoing coronary angiography at three London hospitals. Before patients were recruited, a nine-member expert panel rated the appropriateness of percutaneous transluminal coronary angioplasty (PTCA) and coronary-artery bypass grafting (CABG) on a nine-point scale (with 1 denoting highly inappropriate and 9 denoting highly appropriate) for specific clinical indications. These ratings were then applied to a population of patients with coronary artery disease. However, the patients were treated without regard to the ratings. A total of 2552 patients were followed for a median of 30 months after angiography. RESULTS: Of 908 patients with indications for which PTCA was rated appropriate (score, 7 to 9), 34 percent were treated medically; these patients were more likely to have angina at follow-up than those who underwent PTCA (odds ratio, 1.97; 95 percent confidence interval, 1.29 to 3.00). Of 1353 patients with indications for which CABG was considered appropriate, 26 percent were treated medically; they were more likely than those who underwent CABG to die or have a nonfatal myocardial infarction--the composite primary outcome (hazard ratio, 4.08; 95 percent confidence interval, 2.82 to 5.93)--and to have angina (odds ratio, 3.03; 95 percent confidence interval, 2.08 to 4.42). Furthermore, there was a graded relation between rating and outcome over the entire scale of appropriateness (P for linear trend=0.002). CONCLUSIONS: On the basis of the ratings of the expert panel, we identified substantial underuse of coronary revascularization among patients who were considered appropriate candidates for these procedures. Underuse was associated with adverse clinical outcomes.

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  • In a prospective study of 2552 patients seen in London hospitals who were deemed appropriate for cardiovascular procedures according to standardized criteria, nonwhite patients were more likely to receive only medical treatment, rather than CABG, after controlling for demographic and clinical variables.

    “in a prospective study of 2552 patients seen in London hospitals who were deemed appropriate for cardiovascular procedures according to standardized criteria, Hemingway and coworkers [9] found that nonwhite patients were more likely to receive only medical treatment, rather than CABG, after controlling for demographic and clinical variables.”

    From Unequal treatment: report of the institute of medicine on racial and ethnic disparities in healthcare (2003) · cites this paper as [9]

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  • These differences were not found among white patients similarly deemed appropriate for invasive treatment.

    “These differences were not found among white patients similarly deemed appropriate for invasive treatment.”

    From Unequal treatment: report of the institute of medicine on racial and ethnic disparities in healthcare (2003) · cites this paper as [9]

    The Results identify nonwhite race as a predictor of receiving medical treatment rather than CABG among appropriate candidates. The paper does not report a corresponding analysis showing that the unspecified 'differences' were absent among white patients (searched for white-patient and race-specific comparisons). (LLM, conf=0.75)

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References 33 · Cited by 262

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Authors
Hemingway, H., Crook, A. M., Feder, G., Banerjee, S., Dawson, J. R., Magee, P., Philpott, S., Sanders, J., Wood, A., & Timmis, A. D.
Affiliations
  • University College London (GB)
  • St Bartholomew's Hospital (GB)
  • National Health Service (GB)
ORCID
Venue
New England Journal of Medicine
Publisher
Massachusetts Medical Society
Published
2001-03
Volume
344
Issue
9
Pages
645-654
ISSN
  • 0028-4793 (ISSN-L)
  • 1533-4406
DOI
10.1056/nejm200103013440906
OpenAlex
W2339429909
Cited by
262
References
33
Citations by year
2025: 1 · 2024: 4 · 2023: 1 · 2022: 10 · 2021: 3 · 2020: 8 · 2019: 7 · 2018: 6 · 2017: 13 · 2016: 8 · 2015: 10 · 2014: 4 · 2013: 9 · 2012: 14
FWCI
20.55
Type
journal article
Language
en
Open access
Locations
  • New England Journal of Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • UCL Discovery (University College London) (submittedVersion)
Topics
  • Health Sciences › Medicine › Surgery › Coronary Interventions and Diagnostics
  • Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
  • Health Sciences › Medicine › Surgery › Cardiac and Coronary Surgery Techniques
Keywords
coronary revascularization, percutaneous transluminal coronary angioplasty, coronary artery bypass grafting, coronary artery disease, appropriateness ratings, expert panel ratings, angina pectoris, myocardial infarction, mortality, clinical outcomes
MeSH terms
Angina Pectoris, Coronary Artery Bypass, Coronary Disease, Follow-Up Studies, Health Services Misuse, Humans, London, Mortality, Myocardial Infarction, Prospective Studies, Utilization Review, Angioplasty, Balloon, Coronary, Incidence, Logistic Models, Coronary Angiography, Outcome Assessment, Health Care

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