Literature at a Glance
- Drug-eluting stents decrease the need for revascularization.
- Case volume is related to hospital performance assessment.
- Prolonged QRS duration in patients with CHF is associated with increased morbidity and mortality.
- For out-of-hospital ACLS, vasopressin plus epinephrine is not better than vasopressin alone.
- Oral rivaroxaban is more efficacious than enoxaparin for VTE prophylaxis after total hip replacement.
- LMWH and UFH offer similar perioperative VTE prophylaxis benefit in patients with cancer.
- Salmeterol added to inhaled corticosteroids decreases severe asthma exacerbations.
- Early invasive strategy has unclear benefit in low-risk women with unstable angina or NSTEMI.
- Strategies to prevent contrast-induced acute kidney injury are not uniform.
- Hyperglycemia in hospitalized children is common and associated with ICU admission.
Background: Drug-eluting stents reduce restenosis rates compared to bare-metal stents. However, there is concern drug-eluting stents increase the risk of stent thrombosis leading to MI and death. Prior studies compared patients who received bare-metal versus those who received drug-eluting stents. Outcomes on a population level might provide new insight.
Study design: Observational study.
Setting: 100% national sample of patients 65 and older who received a coronary stent from 2002-05 enrolled in the traditional fee-for-service Medicare program.
Synopsis: 38,917 patients in the pre-drug-eluting-stent era from October 2002 to March 2003 received bare-metal stents. Nearly 62% of 28,086 patients studied from September to December 2003 received drug-eluting stents. The remaining 38.5% received bare-metal stents. Outcomes of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), STEMI, and death were observed through December 31, 2005.
Patients in the drug-eluting-stent era had a lower two-year risk for repeat revascularization compared to patients in the bare-metal-stent era. In the drug-eluting versus bare-metal eras, repeat PCI was 17.1% versus 20.0% (p<0.001) and need for CABG was 2.7% versus 4.2% (p<0.01). Comparing adjusted outcomes for death, or STEMI, at two years, the two groups appeared similar.
The study did have limitations: the data only reflect sirolimus stents, the authors could not assess dual-antiplatelet therapy or obtain information on coronary anatomy or procedure details to account for selection bias in stent utilization, and the patients were all Medicare beneficiaries.
Bottom line: Drug-eluting stents are associated with fewer repeat revascularization procedures than bare-metal stents, but have not shown a significant improvement in the subsequent risk of STEMI or death.
Citation: Malenka DJ, Kaplan AV, Lucas FL, Sharp SM, Skinner JA. Outcomes following coronary stenting in the era of bare-metal vs. the era of drug-eluting stents. JAMA 2008;299(24):2868-2877.
Background: Hospitals are increasingly graded and compared to one another. “Top medical centers” are defined as those within the top 10% of hospitals in specified performance measures. Hospitals with large and small case volumes might not be compared evenly and fairly.
Study design: Eight publicly reported process measures for acute myocardial infarction (AMI) were compared to hospital case volume, process performance, and label as “top hospital.”
Setting: Data were analyzed from the Hospital Quality Alliance for 3,761 hospitals from January to December 2005.
Synopsis: Hospitals with large case volume overall had better process performance. For example, looking at use of beta-blockers in patients with AMI on arrival to a hospital, small-volume hospitals (<10 AMI cases) averaged 72% while large volume (>100 AMI cases) averaged 80% (p<0.001). However, hospitals with small case volumes were more likely to receive “top hospital” rating even when hospitals with very low case volumes were excluded.