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(Circulation. 2008;118:2797-2802.)
© 2008 American Heart Association, Inc.

Health Services and Outcomes Research

Diagnostic-Therapeutic Cascade Revisited

Coronary Angiography, Coronary Artery Bypass Graft Surgery, and Percutaneous Coronary Intervention in the Modern Era

F.L. Lucas, PhD; A.E. Siewers, MPH; D.J. Malenka, MD; D.E. Wennberg, MD, MPH

From the Center for Outcomes Research and Evaluation, Maine Medical Center, Portland (F.L.L., A.E.S.); Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, NH (F.L.L., D.J.M., D.E.W.); Section of Cardiology, Dartmouth-Hitchcock Medical Center, Hanover, NH (D.J.M.); and HealthDialog Analytic Solutions, Portland, Me (D.E.W.).

Correspondence to Dr F. Lee Lucas, Center for Outcomes Research and Evaluation, Maine Medical Center, 22 Bramhall St, Portland, ME 04102. E-mail lucasl{at}mmc.org

Received August 30, 2008; accepted October 15, 2008.

Background— There is wide geographic variation in the use of coronary revascularization in the United States. Rates are closely related to rates of coronary angiography. We assessed the relationship between coronary angiography and coronary artery revascularization by procedure type (coronary artery bypass graft surgery or percutaneous coronary intervention).

Methods and Results— Using Part B claims for a 20% sample of the Medicare population, we calculated population-based rates of testing and treatment by region, using events identified in Part B claims as the numerator and the total number of Medicare beneficiaries residing in the area as the denominator and adjusting for regional differences in demographic characteristics with the indirect method. Cardiac catheterization rates varied substantially across regions, from 16 to 77 per 1000 Medicare beneficiaries. The relationship between coronary angiography rates and total coronary revascularization rates was strong (R²=0.84). However, there was only a modest association between coronary angiography rates and coronary artery bypass graft surgery rates (R²=0.41) with the suggestion of a threshold effect. The association between coronary angiography rates and percutaneous coronary intervention rates was strong (R²=0.78) and linear.

Conclusions— The diagnostic-therapeutic cascade for coronary artery disease differs by therapeutic intervention. For coronary artery bypass graft surgery, the relationship is modest, and there appears to be a testing threshold beyond which additional tests do not result in additional surgeries. For percutaneous coronary intervention, the relationship is very tight, and no threshold appears to exist. Given the results of recent studies of medical versus invasive management of stable coronary disease, patients living in high-diagnostic-intensity regions may be getting more treatment than they want or need.

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