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Angioplasty or bypass surgery? It really depends on the hospital: study


Patients who get chest pain due to severe narrowing of the arteries in the heart have two choices: The first is angioplasty (a procedure where a balloon is inserted and inflated to widen a narrowed or obstructed blood vessel in the heart), and the other is the more traditional coronary bypass surgery (open-heart surgery where a healthy blood vessel from another part of the body is grafted onto the heart to circumvent a blocked artery). In patients with two or three blocked arteries, the choice between these procedures varies significantly across Ontario. According to a new study led by researchers at the Institute for Clinical Evaluative Sciences (ICES) and the Cardiac Care Network of Ontario (CCN), there is a greater than three-fold variation across hospitals in Ontario.

“This significant variation highlights that treatment preferences and practice styles of the cardiologists at different hospitals greatly impacts whether a patient is treated with angioplasty or bypass surgery,” says lead author and ICES Senior Scientist Dr. Jack Tu. “While many patients may still prefer angioplasty because it is less invasive, we recommend that patients receive more information about their treatment choices after a coronary angiogram and that surgeons be consulted more often when surgery is potentially one of the treatment options available,” adds Tu.

The Variations in Revascularization Practices in Ontario (VRPO) study of 8,972 patientss undergoing a coronary angiogram in Ontario between April 2006 and March 2007 found that:

  • A greater than three-fold variation in the ratio of angioplasty to bypass surgery procedures performed in Ontario's hospitals that perform cardiac procedures.
  • The lowest ratios were in Windsor and London Health Sciences heart centres.
  • The highest ratios were in the Sault, Sudbury and Ottawa heart centres.
  • The cardiologist performing the diagnostic angiogram in patients appeared to be a key decision maker as to the type of treatment (medications, angioplasty or bypass surgery) the patient ultimately received.
  • Many two and three-vessel patients were treated with angioplasty immediately after an angiogram without involvement of a cardiac surgeon in the decision-making process.

“While the conclusions of the study are based on a subset of patients and not applicable to all angioplasty vs. bypass surgery decisions, the findings remind us of the need to engage discussion on treatment options, particularly for patients with complex coronary artery blockages for whom either procedure may be an option,” says Kori Kingsbury, CEO at the Cardiac Care Network of Ontario.

According to Dr. Eric A. Cohen, Deputy Head of the Schulich Heart Program, Sunnybrook Health Sciences Centre, and co-lead of the project, “There is considerable variation between hospitals in the use of angioplasty and bypass surgery. We found that much of the decision making between the two procedures is—quite appropriately—based on clinical factors like the location and severity of blocked heart arteries or whether the patient just had a heart attack. However, we found that the treating hospital and the type of specialist involved also influenced the pattern of care. This led us to believe that there could be more consistency and transparency in these sorts of decisions.”

The study was funded by an operating grant from the Ontario Ministry of Health and Long-Term Care.

Author block: Jack V. Tu, Dennis T. Ko, Helen Guo, Janice A. Richards, Nancy Walton, Madhu K Natarajan, Harindra C. Wijeysundera, Derek So, David A. Latter, Christopher M. Feindel, Kori Kingsbury, Eric A. Cohen.

The study “Determinants of variations in coronary revascularization practices” is in the December 12, 2011 issue of CMAJ.

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.

The Cardiac Care Network of Ontario (CCN) is a network of 18 member hospitals providing cardiac services in Ontario. In addition, CCN serves an advisory role on matters pertaining to cardiovascular care, and is a system resource for patients and families, hospitals, Local Health Integration Networks and other stakeholders of the healthcare system in Ontario. In addition to helping plan, coordinate, implement and evaluate cardiovascular care in Ontario, CCN is responsible for developing, maintaining and reporting on the provincial cardiac wait list registry for all patients waiting for selected adult advanced cardiac procedures in Ontario. In the role of monitoring and enhancing quality of cardiac services in Ontario, CCN develops strategies, based on best practices, to better manage cardiovascular disease across the continuum of care, including strategies to prevent acute hospital readmissions, decrease demand on emergency departments and decrease the need for initial and repeat procedures. The Cardiac Care Network of Ontario is funded by the Ontario Ministry of Health and Long-Term Care.

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