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Changes in Mortality after Myocardial Revascularization in the Elderly: The National Medicare Experience

Eric D. Peterson, MD, MPH; James G. Jollis, MD; Judith D. Bebchuk, MS; Elizabeth R. DeLong, PhD; Lawrence H. Muhlbaier, PhD; Daniel B. Mark, MD, MPH; and David B. Pryor, MD
[+] Article and Author Information

From Duke University Medical Center, Durham, North Carolina. Requests for Reprints: Eric D. Peterson, MD, Department of Medicine, Division of Cardiology, Duke University Medical Center, DUMC 3236, Durham, NC 27710-7510. Grant Support: By HS-06503 and HS-05635 from the Agency for Health Care Policy and Research, Rockville, Maryland; HL-17670 from the National Heart Lung and Blood Institute, Bethesda, Maryland; and a grant from the Robert Wood Johnson Foundation, Princeton, New Jersey.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1994;121(12):919-927. doi:10.7326/0003-4819-121-12-199412150-00003
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Objective: To examine secular changes in the use and outcome of percutaneous transluminal coronary angioplasty and cardiac bypass graft surgery in the elderly.

Design: A retrospective cohort study based on a longitudinal database created from the administrative files of Medicare.

Setting: U.S. hospitals that perform myocardial revascularization procedures covered by Medicare.

Patients: 225 915 consecutive patients who had angioplasty and 357 885 consecutive patients who had bypass surgery from 1987 to 1990.

Measurements: The rates of angioplasty and bypass surgery use; unadjusted 30-day and 1-year mortality rates after revascularization; and adjusted odds ratios for mortality by year of procedure for 1987 to 1990.

Results: From 1987 to 1990, the rates of angioplasty 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 1-year mortality rates decreased by 10% (CI, 8% to 11%) and 8% (CI, 7% to 10%), respectively. After adjustment for changes in patient characteristics, 30-day mortality rates after these procedures decreased by 37% (CI, 32% to 41%) and 18% (CI, 14% to 21%), and 1-year mortality rates decreased by 22% (CI, 18% to 25%) and 19% (CI, 16% to 21%), respectively.

Conclusions: The use of cardiac revascularization procedures in the elderly has steadily increased. Patients who had revascularization are progressively older, have more coded comorbid conditions, and present with more acute diseases. Although elderly patients have apparently higher risk profiles, mortality rates after angioplasty and bypass surgery in the elderly have decreased, suggesting a national improvement in the outcomes of these interventions. Health policy decisions concerning revascularization procedures in the elderly must consider these trends in improved outcome.

Figures

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Figure 1.
Unadjusted 30-day and 1-year mortality after angioplasty by year of procedure (1987 to 1990).
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Figure 2.
Unadjusted 30-day and 1-year mortality after bypass surgery by year of procedure (1987 to 1990).
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Figure 3.
Adjusted 30-day and 1-year odds ratio mortality after angioplasty for 1990 and 1987 after controlling for patient age, race, sex, Charlson index score, and acute myocardial infarction on admission.

The 95% confidence intervals for the odds ratio are shown as bars on each side of the point estimate. If the odds ratio and confidence interval are less than 1.0, the adjusted likelihood of mortality after angioplasty in that year is significantly lower than the mortality for procedures done in 1987.

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Figure 4.
Adjusted 30-day and 1-year odds ratio mortality after bypass surgery for 1990 and 1987 after controlling for patient age, race, sex, Charlson index score, and acute myocardial infarction on admission.

The 95% confidence intervals for the odds ratio are shown as bars on each side of the point estimate. If the odds ratio and confidence interval are less than 1.0, the adjusted likelihood of mortality after bypass surgery in that year is significantly lower than the mortality for procedures done in 1987.

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