Declining use rates of revascularization for Medicare patients: is this a real trend?

1 in this issue of Circulation provides useful information about the trends and outcomes of coronary revascularization procedures currently being performed in the United States. Data acquisition for this analysis of coronary revascularization activity from 2008 through 2012 required tedious mining of 2 complex data sets maintained by the Centers for Medicare and Medicaid Services. In addition to the Medicare Provider Analysis and Review file, which contains all inpatient claims for Medicare beneficiaries, they reviewed the Medicare Outpatient File, which contains claims for " nonadmission " services, specifically data on outpatient procedures. This latter review was necessary because many percutaneous coronary interventions (PCIs) are now done in acute hospital settings but with patients classified as outpatients or hospitalized but under observation status. An obvious limitation of this report of current revascularization trends is the fact that only Medicare patient data were analyzed. Coronary revascularizations of Medicare beneficiaries, however, are believed to represent a modest majority of such procedures and to reliably reflect total revascularization activity in the United States. This report presents an exhaustive review of all revascu-larizations performed on Medicare beneficiaries who underwent either PCI or coronary artery bypass grafting (CABG) during the 5-year study period. It is unclear why the authors refer to primary and secondary PCI and CABG. This distinction appears to be meaningless for PCI patients. In addition, they report 90-day postdischarge mortality rates but do not describe how this late postdischarge mortality information was obtained and validated. The principal value of the report is the patient volume information and the analysis of total coronary revascularization procedures done during the recent 5-year period, along with likely accurate early postprocedure mortality data on all Medicare program patients having PCI or CABG surgery during this time. Analysis of the PCI data is straightforward, whereas the CABG data include isolated CABG operations and combined CABG-valve surgery procedures. Combined CABG-valve procedures increased during this 5-year interval. For an undetermined number of these patients, the principal indication for surgery was the condition of the heart valve. In addition, 3% to 4% of CABG patients had PCI performed during the same admission, which suggests that the PCI revascularization procedure may have been ineffective or complicated and may have required immediate CABG surgery. The well-documented decline in CABG surgery that began nearly 20 years ago as PCI case volume increased dramatically continued during this 5-year period. 2–4 This report notes a steady annual …