Comparison of outcomes of percutaneous coronary intervention on proximal versus non-proximal left anterior descending coronary artery, proximal left circumflex, and proximal right coronary artery: a cross-sectional study.

BACKGROUND: Previous studies have shown that lesions in proximal left anterior descending coronary artery (LAD) may develop more restenosis after balloon angioplasty than lesions in other coronary segments. However, stenting seems to have reduced this gap. In this study, we compared outcomes of percutaneous coronary intervention (PCI) on proximal LAD versus proximal left circumflex (LCX) or right coronary artery (RCA) and proximal versus non-proximal LAD. METHODS: From 1737 patients undergoing PCI between March 2004 and 2005, those with cardiogenic shock, primary PCI, total occlusions, and multivessel or multi-lesion PCI were excluded. Baseline characteristics and in-hospital outcomes were compared in 408 patients with PCI on proximal LAD versus 133 patients with PCI on proximal LCX/RCA (study I) and 244 patients with PCI on non-proximal LAD (study II). From our study populations, 449 patients in study I and 549 patients in study II participated in complete follow-up programs, and long-term PCI outcomes were compared within these groups. The statistical methods included Chi-square or Fisher's exact test, student's t-test, stratification methods, multivariate logistic regression and Cox proportional hazards model. RESULTS: In the proximal LAD vs. proximal LCX/RCA groups, smoking and multivessel disease were less frequent and drug-eluting stents were used more often (p = 0.01, p < 0.001, and p < 0.001, respectively). Patients had longer and smaller-diameter stents (p = 0.009, p < 0.001, respectively). In the proximal vs. non-proximal LAD groups, multivessel disease was less frequent (p = 0.05). Patients had larger reference vessel diameters (p < 0.001) and were more frequently treated with stents, especially direct stenting technique (p < 0.001). Angiographic success rate was higher in the proximal LAD versus proximal LCX/RCA and non-proximal LAD groups (p = 0.004 and p = 0.05, respectively). In long-term follow-up, major adverse cardiac events showed no difference. After statistical adjustment for significant demographic, angiographic or procedural characteristics, long-term PCI outcomes were still similar in the proximal LAD versus proximal LCX/RCA and non-proximal LAD groups. CONCLUSION: Despite the known worse prognosis of proximal LAD lesions, in the era of stenting, our long-term outcomes were similar in patients with PCI on proximal LAD versus proximal LCX/RCA and non-proximal LAD. Furthermore, we had better angiographic success rates in patients with PCI on proximal LAD.

The impact of reimbursement changes for intracoronary stents on providers and Medicare.

CONTEXT: New Medicare reimbursement policies will move stents into a different diagnosis-related group (DRG) than conventional balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA]). OBJECTIVE: To examine the financial impact on hospitals and Medicare of these planned changes, taking into account costs, reimbursement, and the cost-offset effect of prevented complications. DESIGN: The economic impact of proposed reimbursement changes was modeled by using a retrospective clinical and economic data set from a single institution. PATIENTS AND METHODS: A total of 421 consecutive interventional cases from 1996 were examined by using actual cost data. The new, proposed revenues were assigned to these cases. From the hospitals' perspective, the focus was on contribution margin (the difference between revenues and costs), risk adjusted for case-mix severity. From Medicare's perspective, the focus was on expenditures. Various assumptions were adopted for two clinical variables: the effectiveness of stents in preventing the major PTCA-related complications of myocardial infarction and coronary artery bypass graft surgery and the relative proportions of myocardial infarction and coronary artery bypass graft surgery in the mix of complications. Under current Medicare DRG policies, coronary artery bypass graft surgery is highly profitable for hospitals, whereas myocardial infarction as a complication of PTCA has a negative financial impact. RESULTS: Under the new Medicare reimbursement policies, hospitals experience higher profitability with stents than with conventional PTCA under most assumed levels of clinical effectiveness and mixes of myocardial infarction and coronary artery bypass graft surgery. For Medicare, under most circumstances (including percentages of stent use and levels of clinical effectiveness that represent contemporary practice) stents lead to greater expenditures. CONCLUSIONS: Medicare reimbursement changes will substantially realign previously misaligned financial and clinical incentives for hospitals. The immediate effect on hospitals will be to enhance profitability, whereas the effect on Medicare will be to increase expenditures.