Mark A. Hlatky, MD; Derek B. Boothroyd, PhD; Laurence Baker, PhD; Dhruv S. Kazi, MD, MS; Matthew D. Solomon, MD, PhD; Tara I. Chang, MD, MS; David Shilane, PhD; Alan S. Go, MD
Grant Support: By grant HL099872 from the National Heart, Lung, and Blood Institute.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1564.
Reproducible Research Statement: Study protocol: The protocol is fully described in the manuscript. Statistical code: Available on request. Data set: Medicare data sets are available to qualified researchers but cannot be released by the investigators.
Requests for Single Reprints: Mark A. Hltaky, MD, Stanford University School of Medicine, HRP Redwood Building, 259 Campus Drive, Stanford, CA 94305-5405; e-mail, email@example.com.
Current Author Addresses: Drs. Hlatky, Boothroyd, Baker, and Shilane: Stanford University School of Medicine, HRP Redwood Building, 259 Campus Drive, Stanford, CA 94305-5405.
Dr. Kazi: UCSF Division of Cardiology, San Francisco General Hospital, 1001 Potrero Avenue, SG1, San Francisco, CA 94110.
Drs. Solomon and Go: Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612.
Dr. Chang: Stanford University School of Medicine, Nephrology Division, 777 Welch Road, Room D100, Palo Alto, CA 94304.
Author Contributions: Conception and design: M.A. Hlatky, L. Baker, A.S. Go.
Analysis and interpretation of the data: M.A. Hlatky, D.B. Boothroyd, D.S. Kazi, M.D. Solomon, T.I. Chang, D. Shilane, A.S. Go.
Drafting of the article: M.A. Hlatky.
Critical revision of the article for important intellectual content: D.B. Boothroyd, D.S. Kazi, M.D. Solomon, T.I. Chang, D. Shilane, A.S. Go.
Final approval of the article: M.A. Hlatky, D.B. Boothroyd, L. Baker, D.S. Kazi, M.D. Solomon, T.I. Chang, D. Shilane, A.S. Go.
Provision of study materials or patients: L. Baker.
Statistical expertise: M.A. Hlatky, D.B. Boothroyd, D. Shilane.
Obtaining of funding: M.A. Hlatky, A.S. Go.
Administrative, technical, or logistic support: M.A. Hlatky, L. Baker.
Collection and assembly of data: D.B. Boothroyd, L. Baker.
Hlatky MA, Boothroyd DB, Baker L, Kazi DS, Solomon MD, Chang TI, et al. Comparative Effectiveness of Multivessel Coronary Bypass Surgery and Multivessel Percutaneous Coronary Intervention: A Cohort Study. Ann Intern Med. 2013;158:727-734. doi: 10.7326/0003-4819-158-10-201305210-00639
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Published: Ann Intern Med. 2013;158(10):727-734.
Randomized trials of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) suggest that patient characteristics modify the effect of treatment on mortality.
To assess whether clinical characteristics modify the comparative effectiveness of CABG versus PCI in an unselected, general patient population.
Observational treatment comparison using propensity score matching and Cox proportional hazards models.
United States, 1992 to 2008.
Medicare beneficiaries aged 66 years or older.
Multivessel CABG or multivessel PCI.
The CABG–PCI hazard ratio (HR) for all-cause mortality, with prespecified treatment-by-covariate interaction tests, and the absolute difference in life-years of survival in clinical subgroups after CABG or PCI, both over 5 years of follow-up.
Among 105 156 propensity score–matched patients, CABG was associated with lower mortality than PCI (HR, 0.92 [95% CI, 0.90 to 0.95]; P < 0.001). Association of CABG with lower mortality was significantly greater (interaction P ≤ 0.002 for each) among patients with diabetes (HR, 0.88), a history of tobacco use (HR, 0.82), heart failure (HR, 0.84), and peripheral arterial disease (HR, 0.85). The overall predicted difference in survival between CABG and PCI treatment over 5 years was 0.053 life-years (range, −0.017 to 0.579 life-years). Patients with diabetes, heart failure, peripheral arterial disease, or tobacco use had the largest predicted differences in survival after CABG, whereas those with none of these factors had slightly better survival after PCI.
Treatments were chosen by patients and physicians rather than being randomly assigned.
Multivessel CABG is associated with lower long-term mortality than multivessel PCI in the community setting. This association is substantially modified by patient characteristics, with improvement in survival concentrated among patients with diabetes, tobacco use, heart failure, or peripheral arterial disease.
National Heart, Lung, and Blood Institute.
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Cardiology, Coronary Heart Disease, Healthcare Delivery and Policy, Percutaneous Coronary Intervention.
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