Dataset Information

Sex and Race Differences in the Utilization and Outcomes of Coronary Artery Bypass Grafting Among Medicare Beneficiaries, 1999-2014.

ABSTRACT: With over a decade of directed efforts to reduce sex and racial differences in coronary artery bypass grafting (CABG) utilization, and post-CABG outcomes, we sought to evaluate how the use of CABG and its outcomes have evolved in different sex and racial subgroups. Using data on all fee-for-service Medicare beneficiaries undergoing CABG in the United States from 1999 to 2014, we examined differences by sex and race in calendar-year trends for CABG utilization and post-CABG outcomes (in-hospital, 30-day, and 1-year mortality and 30-day readmission). A total of 1 863 719 Medicare fee-for-service beneficiaries (33.6% women, 4.6% black) underwent CABG from 1999 to 2014, with a decrease from 611 to 245 CABG procedures per 100 000 person-years. Men compared with women and whites compared with blacks had higher CABG utilization, with declines in all subgroups. Higher post-CABG annual declines in mortality (95% confidence interval) were observed in women (in-hospital, -2.70% [-2.97, -2.44]; 30-day, -2.29% [-2.54, -2.04]; and 1-year mortality, -1.67% [-1.88, -1.46]) and blacks (in-hospital, -3.31% [-4.02, -2.60]; 30-day, -2.80% [-3.49, -2.12]; and 1-year mortality, -2.38% [-2.92, -1.84]), compared with men and whites, respectively. Mortality rates remained higher in women and blacks, but differences narrowed over time. Annual adjusted 30-day readmission rates remained unchanged for all patient groups. Women and black patients had persistently higher CABG mortality than men and white patients, respectively, despite greater declines over the time period. These findings indicate progress, but also the need for further progress.

SUBMITTER: Angraal S

PROVIDER: S-EPMC6064835 | biostudies-literature | 2018 Jul

REPOSITORIES: biostudies-literature

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Sex and Race Differences in the Utilization and Outcomes of Coronary Artery Bypass Grafting Among Medicare Beneficiaries, 1999-2014.

Angraal Suveen S Khera Rohan R Wang Yun Y Lu Yuan Y Jean Raymond R Dreyer Rachel P RP Geirsson Arnar A Desai Nihar R NR Krumholz Harlan M HM

Journal of the American Heart Association 20180712 14

<h4>Background</h4>With over a decade of directed efforts to reduce sex and racial differences in coronary artery bypass grafting (CABG) utilization, and post-CABG outcomes, we sought to evaluate how the use of CABG and its outcomes have evolved in different sex and racial subgroups.<h4>Methods and results</h4>Using data on all fee-for-service Medicare beneficiaries undergoing CABG in the United States from 1999 to 2014, we examined differences by sex and race in calendar-year trends for CABG ut ...[more]

PMID: 30005557

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Project description:Background Over 180 000 coronary artery bypass grafting (CABG) procedures are performed annually, accounting for $7 to $10 billion in episode expenditures. Assessing tradeoffs between spending and quality contributing to value during 90-day episodes has not been conducted but is essential for success in bundled reimbursement models. We, therefore, identified determinants of variability in hospital 90-day episode value for CABG. Methods Medicare and private payor admissions for isolated CABG from 2014 to 2016 were retrospectively linked to clinical registry data for 33 nonfederal hospitals in Michigan. Hospital composite risk-adjusted complication rates (≥1 National Quality Forum-endorsed, Society of Thoracic Surgeons measure: deep sternal wound infection, renal failure, prolonged ventilation >24 hours, stroke, re-exploration, and operative mortality) and 90-day risk-adjusted, price-standardized episode payments were used to categorize hospitals by value by defining the intersection between complications and spending. Results Among 2573 total patients, those at low- versus high-value hospitals had a higher percentage of prolonged length of stay >14 days (9.3% versus 2.4%, P=0.006), prolonged ventilation (17.6% versus 4.8%, P<0.001), and operative mortality (4.8% versus 0.6%, P=0.001). Mean total episode payments were $51 509 at low-compared with $45 526 at high-value hospitals (P<0.001), driven by higher readmission ($3675 versus $2177, P=0.005), professional ($7462 versus $6090, P<0.001), postacute care ($7315 versus $5947, P=0.031), and index hospitalization payments ($33 474 versus $30 800, P<0.001). Among patients not experiencing a complication or 30-day readmission (1923/2573, 74.7%), low-value hospitals had higher inpatient evaluation and management payments ($1405 versus $752, P<0.001) and higher utilization of inpatient rehabilitation (7% versus 2%, P<0.001), but lower utilization of home health (66% versus 73%, P=0.016) and emergency department services (13% versus 17%, P=0.034). Conclusions To succeed in emerging bundled reimbursement programs for CABG, hospitals and physicians should identify strategies to minimize complications while optimizing inpatient evaluation and management spending and use of inpatient rehabilitation, home health, and emergency department services.

Project description:ObjectivesThe aim of this study was to describe the potential of 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) to identify graft vasculopathy and to investigate the influence of coronary artery bypass graft (CABG) surgery on native coronary artery disease activity and progression.BackgroundAs well as developing graft vasculopathy, CABGs have been proposed to accelerate native coronary atherosclerosis.MethodsPatients with established coronary artery disease underwent baseline 18F-NaF PET, coronary artery calcium scoring, coronary computed tomographic angiography, and 1-year repeat coronary artery calcium scoring. Whole-vessel coronary microcalcification activity (CMA) on 18F-NaF PET and change in calcium scores were quantified in patients with and without CABG surgery.ResultsAmong 293 participants (mean age 65 ± 9 years, 84% men), 48 (16%) underwent CABG surgery 2.7 years [IQR: 1.4-10.4 years] previously. Although all arterial and the majority (120 of 128 [94%]) of vein grafts showed no 18F-NaF uptake, 8 saphenous vein grafts in 7 subjects had detectable CMA. Bypassed native coronary arteries had 3 times higher CMA values (2.1 [IQR: 0.4-7.5] vs 0.6 [IQR: 0-2.7]; P < 0.001) and greater progression of 1-year calcium scores (118 Agatston unit [IQR: 48-194 Agatston unit] vs 69 [IQR: 21-142 Agatston unit]; P = 0.01) compared with patients who had not undergone CABG, an effect confined largely to native coronary plaques proximal to the graft anastomosis. In sensitivity analysis, bypassed native coronary arteries had higher CMA (2.0 [IQR: 0.4-7.5] vs 0.8 [IQR: 0.3-3.2]; P < 0.001) and faster disease progression (24% [IQR: 16%-43%] vs 8% [IQR: 0%-24%]; P = 0.002) than matched patients (n = 48) with comparable burdens of coronary artery disease and cardiovascular comorbidities in the absence of bypass grafting.ConclusionsNative coronary arteries that have been bypassed demonstrate increased disease activity and more rapid disease progression than nonbypassed arteries, an observation that appears independent of baseline atherosclerotic plaque burden. Microcalcification activity is not a dominant feature of graft vasculopathy.

Dataset Information

Sex and Race Differences in the Utilization and Outcomes of Coronary Artery Bypass Grafting Among Medicare Beneficiaries, 1999-2014.

Publications

Sex and Race Differences in the Utilization and Outcomes of Coronary Artery Bypass Grafting Among Medicare Beneficiaries, 1999-2014.

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