Mary Ann Moon

The magnitude of the absolute risk for atypical fractures of the femoral shaft among women taking bisphosphonates is small, according to a report in the May 5 issue of the New England Journal of Medicine.

The absolute risk remains small even though there is a high prevalence of use of the drugs among patients who develop such fractures. Moreover, that risk is small enough to be easily outweighed by bisphosphonates’ benefit in preventing fractures, said Dr. Jörg Schilcher of Linköping (Sweden) University and his associates.

These findings, from nationwide population-based analyses of data on all 12,777 women in Sweden who were aged 55 and older and sustained a femoral fracture in 2008, "should be reassuring for bisphosphonate users," they noted.

The investigators first reviewed the radiographs of all femoral subtrochanteric and shaft fractures that were treated throughout Sweden that year. They identified the 1,234 cases among older women that resulted from falls.

The researchers then identified 47 cases of typical stress fractures (transverse on the lateral side without intermediate fragments, plus a thickening of the lateral cortex at the fracture site and no involvement of the trochanteric or condylar areas). A second group of 12 patients had suspected stress fractures with the same characteristics as the fractures in the first group, but either without a thickening of the lateral cortex or with an intermediate fragment. In a case-control analysis, the researchers compared bisphosphonate use between these 59 women and some 263 women who were chosen as control subjects and did not have stress fractures but who did have breaks in similar locations that were considered suitable for comparison.

The prevalence of bisphosphonate use was much higher among subjects with atypical stress fractures (78%) than among the control subjects (10%). However, the absolute risk of sustaining an atypical fracture while using bisphosphonates was small: 5 cases per 10,000 patient-years.

This translates to a number needed to harm of 2,000 for every year of use; that is, 2,000 bisphosphonate users would be needed for one case of drug-related atypical fracture to occur per year.

Thus, "the benefits of fracture prevention with bisphosphonate use will greatly outweigh the risk of atypical femoral fracture," Dr. Schilcher and his colleagues said (N. Engl. J. Med. 2011;364:1728-37).

The risk of these atypical femoral fractures also appeared to be unrelated to the use of systemic glucocorticoids and other medications that affect bone. "It has been proposed that glucocorticoids and proton pump inhibitors are likely to contribute to the risk of atypical fractures, but our data suggest that this is not the case," they added.

The risk of atypical femoral fracture also was independent of coexisting conditions and of patient age in this study population.

Previous studies that suggested that bisphosphonates raised the absolute risk of atypical femoral fractures to an unacceptable degree "relied on registry data or hospital records," whereas this study relied on direct examination and classification of fractures from radiographs. "The specific radiographic classification is important, since our analysis shows that the rare atypical femoral fracture will be overshadowed by other types of fractures in registry studies, impeding the detection of their association with bisphosphonates," the investigators noted.

This study was limited in that it did not assess long-term bisphosphonate use or bone density. It also included only women of Northern European ethnicity, so the results may not be generalizable to men and other ethnic groups, they added.

This study was funded by the Swedish Research Council. Dr. Schilcher’s associate reported ties to Eli Lilly and Amgen, and holds stock in AddBIO, a company that is attempting to commercialize a method for bisphosphonate coating of implants to be inserted in bone and that holds a patent on that method.

The magnitude of the absolute risk for atypical fractures of the femoral shaft among women taking bisphosphonates is small, according to a report in the May 5 issue of the New England Journal of Medicine.

The absolute risk remains small even though there is a high prevalence of use of the drugs among patients who develop such fractures. Moreover, that risk is small enough to be easily outweighed by bisphosphonates’ benefit in preventing fractures, said Dr. Jörg Schilcher of Linköping (Sweden) University and his associates.

These findings, from nationwide population-based analyses of data on all 12,777 women in Sweden who were aged 55 and older and sustained a femoral fracture in 2008, "should be reassuring for bisphosphonate users," they noted.

The investigators first reviewed the radiographs of all femoral subtrochanteric and shaft fractures that were treated throughout Sweden that year. They identified the 1,234 cases among older women that resulted from falls.

The researchers then identified 47 cases of typical stress fractures (transverse on the lateral side without intermediate fragments, plus a thickening of the lateral cortex at the fracture site and no involvement of the trochanteric or condylar areas). A second group of 12 patients had suspected stress fractures with the same characteristics as the fractures in the first group, but either without a thickening of the lateral cortex or with an intermediate fragment. In a case-control analysis, the researchers compared bisphosphonate use between these 59 women and some 263 women who were chosen as control subjects and did not have stress fractures but who did have breaks in similar locations that were considered suitable for comparison.

The prevalence of bisphosphonate use was much higher among subjects with atypical stress fractures (78%) than among the control subjects (10%). However, the absolute risk of sustaining an atypical fracture while using bisphosphonates was small: 5 cases per 10,000 patient-years.

This translates to a number needed to harm of 2,000 for every year of use; that is, 2,000 bisphosphonate users would be needed for one case of drug-related atypical fracture to occur per year.

Thus, "the benefits of fracture prevention with bisphosphonate use will greatly outweigh the risk of atypical femoral fracture," Dr. Schilcher and his colleagues said (N. Engl. J. Med. 2011;364:1728-37).

The risk of these atypical femoral fractures also appeared to be unrelated to the use of systemic glucocorticoids and other medications that affect bone. "It has been proposed that glucocorticoids and proton pump inhibitors are likely to contribute to the risk of atypical fractures, but our data suggest that this is not the case," they added.

The risk of atypical femoral fracture also was independent of coexisting conditions and of patient age in this study population.

Previous studies that suggested that bisphosphonates raised the absolute risk of atypical femoral fractures to an unacceptable degree "relied on registry data or hospital records," whereas this study relied on direct examination and classification of fractures from radiographs. "The specific radiographic classification is important, since our analysis shows that the rare atypical femoral fracture will be overshadowed by other types of fractures in registry studies, impeding the detection of their association with bisphosphonates," the investigators noted.

This study was limited in that it did not assess long-term bisphosphonate use or bone density. It also included only women of Northern European ethnicity, so the results may not be generalizable to men and other ethnic groups, they added.

This study was funded by the Swedish Research Council. Dr. Schilcher’s associate reported ties to Eli Lilly and Amgen, and holds stock in AddBIO, a company that is attempting to commercialize a method for bisphosphonate coating of implants to be inserted in bone and that holds a patent on that method.

The magnitude of the absolute risk for atypical fractures of the femoral shaft among women taking bisphosphonates is small, according to a report in the May 5 issue of the New England Journal of Medicine.

The absolute risk remains small even though there is a high prevalence of use of the drugs among patients who develop such fractures. Moreover, that risk is small enough to be easily outweighed by bisphosphonates’ benefit in preventing fractures, said Dr. Jörg Schilcher of Linköping (Sweden) University and his associates.

These findings, from nationwide population-based analyses of data on all 12,777 women in Sweden who were aged 55 and older and sustained a femoral fracture in 2008, "should be reassuring for bisphosphonate users," they noted.

The investigators first reviewed the radiographs of all femoral subtrochanteric and shaft fractures that were treated throughout Sweden that year. They identified the 1,234 cases among older women that resulted from falls.

The researchers then identified 47 cases of typical stress fractures (transverse on the lateral side without intermediate fragments, plus a thickening of the lateral cortex at the fracture site and no involvement of the trochanteric or condylar areas). A second group of 12 patients had suspected stress fractures with the same characteristics as the fractures in the first group, but either without a thickening of the lateral cortex or with an intermediate fragment. In a case-control analysis, the researchers compared bisphosphonate use between these 59 women and some 263 women who were chosen as control subjects and did not have stress fractures but who did have breaks in similar locations that were considered suitable for comparison.

The prevalence of bisphosphonate use was much higher among subjects with atypical stress fractures (78%) than among the control subjects (10%). However, the absolute risk of sustaining an atypical fracture while using bisphosphonates was small: 5 cases per 10,000 patient-years.

This translates to a number needed to harm of 2,000 for every year of use; that is, 2,000 bisphosphonate users would be needed for one case of drug-related atypical fracture to occur per year.

Thus, "the benefits of fracture prevention with bisphosphonate use will greatly outweigh the risk of atypical femoral fracture," Dr. Schilcher and his colleagues said (N. Engl. J. Med. 2011;364:1728-37).

The risk of these atypical femoral fractures also appeared to be unrelated to the use of systemic glucocorticoids and other medications that affect bone. "It has been proposed that glucocorticoids and proton pump inhibitors are likely to contribute to the risk of atypical fractures, but our data suggest that this is not the case," they added.

The risk of atypical femoral fracture also was independent of coexisting conditions and of patient age in this study population.

Previous studies that suggested that bisphosphonates raised the absolute risk of atypical femoral fractures to an unacceptable degree "relied on registry data or hospital records," whereas this study relied on direct examination and classification of fractures from radiographs. "The specific radiographic classification is important, since our analysis shows that the rare atypical femoral fracture will be overshadowed by other types of fractures in registry studies, impeding the detection of their association with bisphosphonates," the investigators noted.

This study was limited in that it did not assess long-term bisphosphonate use or bone density. It also included only women of Northern European ethnicity, so the results may not be generalizable to men and other ethnic groups, they added.

This study was funded by the Swedish Research Council. Dr. Schilcher’s associate reported ties to Eli Lilly and Amgen, and holds stock in AddBIO, a company that is attempting to commercialize a method for bisphosphonate coating of implants to be inserted in bone and that holds a patent on that method.

The magnitude of the absolute risk for atypical fractures of the femoral shaft among women taking bisphosphonates is small, according to a report in the May 5 issue of the New England Journal of Medicine.

The absolute risk remains small even though there is a high prevalence of use of the drugs among patients who develop such fractures. Moreover, that risk is small enough to be easily outweighed by bisphosphonates’ benefit in preventing fractures, said Dr. Jörg Schilcher of Linköping (Sweden) University and his associates.

These findings, from nationwide population-based analyses of data on all 12,777 women in Sweden who were aged 55 and older and sustained a femoral fracture in 2008, "should be reassuring for bisphosphonate users," they noted.

The investigators first reviewed the radiographs of all femoral subtrochanteric and shaft fractures that were treated throughout Sweden that year. They identified the 1,234 cases among older women that resulted from falls.

The researchers then identified 47 cases of typical stress fractures (transverse on the lateral side without intermediate fragments, plus a thickening of the lateral cortex at the fracture site and no involvement of the trochanteric or condylar areas). A second group of 12 patients had suspected stress fractures with the same characteristics as the fractures in the first group, but either without a thickening of the lateral cortex or with an intermediate fragment. In a case-control analysis, the researchers compared bisphosphonate use between these 59 women and some 263 women who were chosen as control subjects and did not have stress fractures but who did have breaks in similar locations that were considered suitable for comparison.

The prevalence of bisphosphonate use was much higher among subjects with atypical stress fractures (78%) than among the control subjects (10%). However, the absolute risk of sustaining an atypical fracture while using bisphosphonates was small: 5 cases per 10,000 patient-years.

This translates to a number needed to harm of 2,000 for every year of use; that is, 2,000 bisphosphonate users would be needed for one case of drug-related atypical fracture to occur per year.

Thus, "the benefits of fracture prevention with bisphosphonate use will greatly outweigh the risk of atypical femoral fracture," Dr. Schilcher and his colleagues said (N. Engl. J. Med. 2011;364:1728-37).

The risk of these atypical femoral fractures also appeared to be unrelated to the use of systemic glucocorticoids and other medications that affect bone. "It has been proposed that glucocorticoids and proton pump inhibitors are likely to contribute to the risk of atypical fractures, but our data suggest that this is not the case," they added.

The risk of atypical femoral fracture also was independent of coexisting conditions and of patient age in this study population.

Previous studies that suggested that bisphosphonates raised the absolute risk of atypical femoral fractures to an unacceptable degree "relied on registry data or hospital records," whereas this study relied on direct examination and classification of fractures from radiographs. "The specific radiographic classification is important, since our analysis shows that the rare atypical femoral fracture will be overshadowed by other types of fractures in registry studies, impeding the detection of their association with bisphosphonates," the investigators noted.

This study was limited in that it did not assess long-term bisphosphonate use or bone density. It also included only women of Northern European ethnicity, so the results may not be generalizable to men and other ethnic groups, they added.

This study was funded by the Swedish Research Council. Dr. Schilcher’s associate reported ties to Eli Lilly and Amgen, and holds stock in AddBIO, a company that is attempting to commercialize a method for bisphosphonate coating of implants to be inserted in bone and that holds a patent on that method.

The magnitude of the absolute risk for atypical fractures of the femoral shaft among women taking bisphosphonates is small, according to a report in the May 5 issue of the New England Journal of Medicine.

The absolute risk remains small even though there is a high prevalence of use of the drugs among patients who develop such fractures. Moreover, that risk is small enough to be easily outweighed by bisphosphonates’ benefit in preventing fractures, said Dr. Jörg Schilcher of Linköping (Sweden) University and his associates.

These findings, from nationwide population-based analyses of data on all 12,777 women in Sweden who were aged 55 and older and sustained a femoral fracture in 2008, "should be reassuring for bisphosphonate users," they noted.

The investigators first reviewed the radiographs of all femoral subtrochanteric and shaft fractures that were treated throughout Sweden that year. They identified the 1,234 cases among older women that resulted from falls.

The researchers then identified 47 cases of typical stress fractures (transverse on the lateral side without intermediate fragments, plus a thickening of the lateral cortex at the fracture site and no involvement of the trochanteric or condylar areas). A second group of 12 patients had suspected stress fractures with the same characteristics as the fractures in the first group, but either without a thickening of the lateral cortex or with an intermediate fragment. In a case-control analysis, the researchers compared bisphosphonate use between these 59 women and some 263 women who were chosen as control subjects and did not have stress fractures but who did have breaks in similar locations that were considered suitable for comparison.

The prevalence of bisphosphonate use was much higher among subjects with atypical stress fractures (78%) than among the control subjects (10%). However, the absolute risk of sustaining an atypical fracture while using bisphosphonates was small: 5 cases per 10,000 patient-years.

This translates to a number needed to harm of 2,000 for every year of use; that is, 2,000 bisphosphonate users would be needed for one case of drug-related atypical fracture to occur per year.

Thus, "the benefits of fracture prevention with bisphosphonate use will greatly outweigh the risk of atypical femoral fracture," Dr. Schilcher and his colleagues said (N. Engl. J. Med. 2011;364:1728-37).

The risk of these atypical femoral fractures also appeared to be unrelated to the use of systemic glucocorticoids and other medications that affect bone. "It has been proposed that glucocorticoids and proton pump inhibitors are likely to contribute to the risk of atypical fractures, but our data suggest that this is not the case," they added.

The risk of atypical femoral fracture also was independent of coexisting conditions and of patient age in this study population.

Previous studies that suggested that bisphosphonates raised the absolute risk of atypical femoral fractures to an unacceptable degree "relied on registry data or hospital records," whereas this study relied on direct examination and classification of fractures from radiographs. "The specific radiographic classification is important, since our analysis shows that the rare atypical femoral fracture will be overshadowed by other types of fractures in registry studies, impeding the detection of their association with bisphosphonates," the investigators noted.

This study was limited in that it did not assess long-term bisphosphonate use or bone density. It also included only women of Northern European ethnicity, so the results may not be generalizable to men and other ethnic groups, they added.

This study was funded by the Swedish Research Council. Dr. Schilcher’s associate reported ties to Eli Lilly and Amgen, and holds stock in AddBIO, a company that is attempting to commercialize a method for bisphosphonate coating of implants to be inserted in bone and that holds a patent on that method.

The magnitude of the absolute risk for atypical fractures of the femoral shaft among women taking bisphosphonates is small, according to a report in the May 5 issue of the New England Journal of Medicine.

The absolute risk remains small even though there is a high prevalence of use of the drugs among patients who develop such fractures. Moreover, that risk is small enough to be easily outweighed by bisphosphonates’ benefit in preventing fractures, said Dr. Jörg Schilcher of Linköping (Sweden) University and his associates.

These findings, from nationwide population-based analyses of data on all 12,777 women in Sweden who were aged 55 and older and sustained a femoral fracture in 2008, "should be reassuring for bisphosphonate users," they noted.

The investigators first reviewed the radiographs of all femoral subtrochanteric and shaft fractures that were treated throughout Sweden that year. They identified the 1,234 cases among older women that resulted from falls.

The researchers then identified 47 cases of typical stress fractures (transverse on the lateral side without intermediate fragments, plus a thickening of the lateral cortex at the fracture site and no involvement of the trochanteric or condylar areas). A second group of 12 patients had suspected stress fractures with the same characteristics as the fractures in the first group, but either without a thickening of the lateral cortex or with an intermediate fragment. In a case-control analysis, the researchers compared bisphosphonate use between these 59 women and some 263 women who were chosen as control subjects and did not have stress fractures but who did have breaks in similar locations that were considered suitable for comparison.

The prevalence of bisphosphonate use was much higher among subjects with atypical stress fractures (78%) than among the control subjects (10%). However, the absolute risk of sustaining an atypical fracture while using bisphosphonates was small: 5 cases per 10,000 patient-years.

This translates to a number needed to harm of 2,000 for every year of use; that is, 2,000 bisphosphonate users would be needed for one case of drug-related atypical fracture to occur per year.

Thus, "the benefits of fracture prevention with bisphosphonate use will greatly outweigh the risk of atypical femoral fracture," Dr. Schilcher and his colleagues said (N. Engl. J. Med. 2011;364:1728-37).

The risk of these atypical femoral fractures also appeared to be unrelated to the use of systemic glucocorticoids and other medications that affect bone. "It has been proposed that glucocorticoids and proton pump inhibitors are likely to contribute to the risk of atypical fractures, but our data suggest that this is not the case," they added.

The risk of atypical femoral fracture also was independent of coexisting conditions and of patient age in this study population.

Previous studies that suggested that bisphosphonates raised the absolute risk of atypical femoral fractures to an unacceptable degree "relied on registry data or hospital records," whereas this study relied on direct examination and classification of fractures from radiographs. "The specific radiographic classification is important, since our analysis shows that the rare atypical femoral fracture will be overshadowed by other types of fractures in registry studies, impeding the detection of their association with bisphosphonates," the investigators noted.

This study was limited in that it did not assess long-term bisphosphonate use or bone density. It also included only women of Northern European ethnicity, so the results may not be generalizable to men and other ethnic groups, they added.

This study was funded by the Swedish Research Council. Dr. Schilcher’s associate reported ties to Eli Lilly and Amgen, and holds stock in AddBIO, a company that is attempting to commercialize a method for bisphosphonate coating of implants to be inserted in bone and that holds a patent on that method.

The rate of coronary artery bypass grafting in U.S. hospitals declined by approximately one-third between 2001 and 2008, according to an analysis of the Agency for Healthcare Research and Quality database reported in the May 4 issue of JAMA.

During the same period, the rate of percutaneous coronary interventions (PCIs) showed a far more modest decrease. "Our data imply a sizeable shift in cardiovascular clinical practice patterns away from surgical treatment toward percutaneous, catheter-based interventions," said Andrew J. Epstein, Ph.D., of the Philadelphia Veterans Affairs’ Center for Health Equity Research and Promotion and the University of Pennsylvania, and his associates.

Given that coronary artery bypass grafting remains the better choice for patients with previously untreated three-vessel or left main coronary artery disease, according to the results of the SYNTAX trial (N. Engl. J. Med. 2009;360:961-72), it appears that CABG is being underused, the authors wrote. It seems likely that in recent years, "patients who would have been optimally treated with CABG surgery were instead treated with PCI," they noted.

To assess temporal trends in coronary revascularization procedures, the investigators examined a nationally representative sample of hospitalization claims using an Agency for Healthcare Research and Quality database. The database includes discharge data from approximately 1,000 nonfederal hospitals in 42 states, which covers 20% of U.S. hospitals and allows accurate estimates for the entire population of hospitalized patients, regardless of payer or insurance status.

Between 2001 and 2008, the total number of coronary revascularizations decreased "modestly," by approximately 15%.

There was a "substantial," statistically significant, 38% decrease in the annual rate of CABG surgery, from 1,742 per million adults in the first year of the study period to 1,081 per million in the final year. This decline was roughly linear throughout the 8-year study period, suggesting that it "was not triggered by any single event occurring during the past decade, such as the introduction of competing technologies, advances in CABG surgical techniques, publication of clinical trials, or issuance of clinical guidelines."

CABG procedures decreased across all sex, age, racial, and regional subgroups.

In contrast, the PCI rate remained fairly constant, showing a "modest" 4% decrease from 3,827 per million adults per year in the first year of the study to 3,667 in the final year.

"Projected to the entire U.S. population, these rate changes implied that 130,000 fewer CABG surgeries were performed in 2008 compared to 2001," Dr. Epstein and his colleagues noted (JAMA 2011;305:1769-76).

The data did not allow the researchers to distinguish which patients may have been more appropriate candidates for CABG than for PCI, so "it cannot be known with certainty whether physicians were increasingly substituting PCI for CABG surgery during the past decade. ... [But] our findings suggest the possibility that several thousand patients who underwent PCI in 2008 would have undergone CABG surgery had patterns of care not changed markedly," they said.

The preferences of patients were also not discernible from the data, lead investigator Dr. Peter W. Groeneveld said in an interview. "However, if patient preference [for PCI vs. CABG] was the driving factor, there would have to be some reason that PCI was even more preferable to patients in 2008 than it was in 2001. This scenario seems unlikely since the procedures haven’t changed that much," said Dr. Groeneveld, assistant professor of medicine at the University of Pennsylvania and staff physician at the Philadelphia Veterans Affairs Medical Center.

Another important finding was that during this interval, the number of hospitals providing CABG increased. Combined with the drop in the number of CABG surgeries, this resulted in a 28% decline in the median caseload per hospital, "and a substantial increase in the number of hospitals that provided fewer than 100 CABG surgeries per year."

Whether or not low-volume centers inherently have worse CABG outcomes can be debated, but either way "our findings highlight the increasing role of low-volume hospitals in the provision of CABG surgery," Dr. Epstein and his associates said.

The final trend in coronary revascularizations revealed in these data was the marked surge in PCI procedures using drug-eluting stents soon after two devices were approved by the Food and Drug Administration in 2003. By mid-2005, 90% of PCI procedures involved drug-eluting stents, reflecting "a high level of clinician enthusiasm" for the devices.

This peak was soon followed by a marked decline after the publication of safety concerns such as late in-stent thrombosis, "as well as increasing clinician awareness of the imperative for ... adherence to long-duration antiplatelet therapy." By the beginning of 2008, only 61% of PCI procedures involved placement of drug-eluting stents, but that rate increased steadily during that year, which also saw the adoption of second-generation stents that carried lower restenosis rates.

"An important implication of this volatility is that thousands of patients may have received drug-eluting stents during the peak years who would have received bare-metal stents [in later years]. Whether these patients were appropriately treated ... during these years of ‘high enthusiasm’ for drug-eluting stents is uncertain," the investigators noted.

This study was supported by the National Heart, Lung, and Blood Institute; the Agency for Healthcare Research and Quality; and the Pennsylvania Department of Health.

The rate of coronary artery bypass grafting in U.S. hospitals declined by approximately one-third between 2001 and 2008, according to an analysis of the Agency for Healthcare Research and Quality database reported in the May 4 issue of JAMA.

During the same period, the rate of percutaneous coronary interventions (PCIs) showed a far more modest decrease. "Our data imply a sizeable shift in cardiovascular clinical practice patterns away from surgical treatment toward percutaneous, catheter-based interventions," said Andrew J. Epstein, Ph.D., of the Philadelphia Veterans Affairs’ Center for Health Equity Research and Promotion and the University of Pennsylvania, and his associates.

Given that coronary artery bypass grafting remains the better choice for patients with previously untreated three-vessel or left main coronary artery disease, according to the results of the SYNTAX trial (N. Engl. J. Med. 2009;360:961-72), it appears that CABG is being underused, the authors wrote. It seems likely that in recent years, "patients who would have been optimally treated with CABG surgery were instead treated with PCI," they noted.

To assess temporal trends in coronary revascularization procedures, the investigators examined a nationally representative sample of hospitalization claims using an Agency for Healthcare Research and Quality database. The database includes discharge data from approximately 1,000 nonfederal hospitals in 42 states, which covers 20% of U.S. hospitals and allows accurate estimates for the entire population of hospitalized patients, regardless of payer or insurance status.

Between 2001 and 2008, the total number of coronary revascularizations decreased "modestly," by approximately 15%.

There was a "substantial," statistically significant, 38% decrease in the annual rate of CABG surgery, from 1,742 per million adults in the first year of the study period to 1,081 per million in the final year. This decline was roughly linear throughout the 8-year study period, suggesting that it "was not triggered by any single event occurring during the past decade, such as the introduction of competing technologies, advances in CABG surgical techniques, publication of clinical trials, or issuance of clinical guidelines."

CABG procedures decreased across all sex, age, racial, and regional subgroups.

In contrast, the PCI rate remained fairly constant, showing a "modest" 4% decrease from 3,827 per million adults per year in the first year of the study to 3,667 in the final year.

"Projected to the entire U.S. population, these rate changes implied that 130,000 fewer CABG surgeries were performed in 2008 compared to 2001," Dr. Epstein and his colleagues noted (JAMA 2011;305:1769-76).

The data did not allow the researchers to distinguish which patients may have been more appropriate candidates for CABG than for PCI, so "it cannot be known with certainty whether physicians were increasingly substituting PCI for CABG surgery during the past decade. ... [But] our findings suggest the possibility that several thousand patients who underwent PCI in 2008 would have undergone CABG surgery had patterns of care not changed markedly," they said.

The preferences of patients were also not discernible from the data, lead investigator Dr. Peter W. Groeneveld said in an interview. "However, if patient preference [for PCI vs. CABG] was the driving factor, there would have to be some reason that PCI was even more preferable to patients in 2008 than it was in 2001. This scenario seems unlikely since the procedures haven’t changed that much," said Dr. Groeneveld, assistant professor of medicine at the University of Pennsylvania and staff physician at the Philadelphia Veterans Affairs Medical Center.

Another important finding was that during this interval, the number of hospitals providing CABG increased. Combined with the drop in the number of CABG surgeries, this resulted in a 28% decline in the median caseload per hospital, "and a substantial increase in the number of hospitals that provided fewer than 100 CABG surgeries per year."

Whether or not low-volume centers inherently have worse CABG outcomes can be debated, but either way "our findings highlight the increasing role of low-volume hospitals in the provision of CABG surgery," Dr. Epstein and his associates said.

The final trend in coronary revascularizations revealed in these data was the marked surge in PCI procedures using drug-eluting stents soon after two devices were approved by the Food and Drug Administration in 2003. By mid-2005, 90% of PCI procedures involved drug-eluting stents, reflecting "a high level of clinician enthusiasm" for the devices.

This peak was soon followed by a marked decline after the publication of safety concerns such as late in-stent thrombosis, "as well as increasing clinician awareness of the imperative for ... adherence to long-duration antiplatelet therapy." By the beginning of 2008, only 61% of PCI procedures involved placement of drug-eluting stents, but that rate increased steadily during that year, which also saw the adoption of second-generation stents that carried lower restenosis rates.

"An important implication of this volatility is that thousands of patients may have received drug-eluting stents during the peak years who would have received bare-metal stents [in later years]. Whether these patients were appropriately treated ... during these years of ‘high enthusiasm’ for drug-eluting stents is uncertain," the investigators noted.

This study was supported by the National Heart, Lung, and Blood Institute; the Agency for Healthcare Research and Quality; and the Pennsylvania Department of Health.

The rate of coronary artery bypass grafting in U.S. hospitals declined by approximately one-third between 2001 and 2008, according to an analysis of the Agency for Healthcare Research and Quality database reported in the May 4 issue of JAMA.

During the same period, the rate of percutaneous coronary interventions (PCIs) showed a far more modest decrease. "Our data imply a sizeable shift in cardiovascular clinical practice patterns away from surgical treatment toward percutaneous, catheter-based interventions," said Andrew J. Epstein, Ph.D., of the Philadelphia Veterans Affairs’ Center for Health Equity Research and Promotion and the University of Pennsylvania, and his associates.

Given that coronary artery bypass grafting remains the better choice for patients with previously untreated three-vessel or left main coronary artery disease, according to the results of the SYNTAX trial (N. Engl. J. Med. 2009;360:961-72), it appears that CABG is being underused, the authors wrote. It seems likely that in recent years, "patients who would have been optimally treated with CABG surgery were instead treated with PCI," they noted.

To assess temporal trends in coronary revascularization procedures, the investigators examined a nationally representative sample of hospitalization claims using an Agency for Healthcare Research and Quality database. The database includes discharge data from approximately 1,000 nonfederal hospitals in 42 states, which covers 20% of U.S. hospitals and allows accurate estimates for the entire population of hospitalized patients, regardless of payer or insurance status.

Between 2001 and 2008, the total number of coronary revascularizations decreased "modestly," by approximately 15%.

There was a "substantial," statistically significant, 38% decrease in the annual rate of CABG surgery, from 1,742 per million adults in the first year of the study period to 1,081 per million in the final year. This decline was roughly linear throughout the 8-year study period, suggesting that it "was not triggered by any single event occurring during the past decade, such as the introduction of competing technologies, advances in CABG surgical techniques, publication of clinical trials, or issuance of clinical guidelines."

CABG procedures decreased across all sex, age, racial, and regional subgroups.

In contrast, the PCI rate remained fairly constant, showing a "modest" 4% decrease from 3,827 per million adults per year in the first year of the study to 3,667 in the final year.

"Projected to the entire U.S. population, these rate changes implied that 130,000 fewer CABG surgeries were performed in 2008 compared to 2001," Dr. Epstein and his colleagues noted (JAMA 2011;305:1769-76).

The data did not allow the researchers to distinguish which patients may have been more appropriate candidates for CABG than for PCI, so "it cannot be known with certainty whether physicians were increasingly substituting PCI for CABG surgery during the past decade. ... [But] our findings suggest the possibility that several thousand patients who underwent PCI in 2008 would have undergone CABG surgery had patterns of care not changed markedly," they said.

The preferences of patients were also not discernible from the data, lead investigator Dr. Peter W. Groeneveld said in an interview. "However, if patient preference [for PCI vs. CABG] was the driving factor, there would have to be some reason that PCI was even more preferable to patients in 2008 than it was in 2001. This scenario seems unlikely since the procedures haven’t changed that much," said Dr. Groeneveld, assistant professor of medicine at the University of Pennsylvania and staff physician at the Philadelphia Veterans Affairs Medical Center.

Another important finding was that during this interval, the number of hospitals providing CABG increased. Combined with the drop in the number of CABG surgeries, this resulted in a 28% decline in the median caseload per hospital, "and a substantial increase in the number of hospitals that provided fewer than 100 CABG surgeries per year."

Whether or not low-volume centers inherently have worse CABG outcomes can be debated, but either way "our findings highlight the increasing role of low-volume hospitals in the provision of CABG surgery," Dr. Epstein and his associates said.

The final trend in coronary revascularizations revealed in these data was the marked surge in PCI procedures using drug-eluting stents soon after two devices were approved by the Food and Drug Administration in 2003. By mid-2005, 90% of PCI procedures involved drug-eluting stents, reflecting "a high level of clinician enthusiasm" for the devices.

This peak was soon followed by a marked decline after the publication of safety concerns such as late in-stent thrombosis, "as well as increasing clinician awareness of the imperative for ... adherence to long-duration antiplatelet therapy." By the beginning of 2008, only 61% of PCI procedures involved placement of drug-eluting stents, but that rate increased steadily during that year, which also saw the adoption of second-generation stents that carried lower restenosis rates.

"An important implication of this volatility is that thousands of patients may have received drug-eluting stents during the peak years who would have received bare-metal stents [in later years]. Whether these patients were appropriately treated ... during these years of ‘high enthusiasm’ for drug-eluting stents is uncertain," the investigators noted.

This study was supported by the National Heart, Lung, and Blood Institute; the Agency for Healthcare Research and Quality; and the Pennsylvania Department of Health.

The rate of coronary artery bypass grafting in U.S. hospitals declined by approximately one-third between 2001 and 2008, according to an analysis of the Agency for Healthcare Research and Quality database reported in the May 4 issue of JAMA.

During the same period, the rate of percutaneous coronary interventions (PCIs) showed a far more modest decrease. "Our data imply a sizeable shift in cardiovascular clinical practice patterns away from surgical treatment toward percutaneous, catheter-based interventions," said Andrew J. Epstein, Ph.D., of the Philadelphia Veterans Affairs’ Center for Health Equity Research and Promotion and the University of Pennsylvania, and his associates.

Given that coronary artery bypass grafting remains the better choice for patients with previously untreated three-vessel or left main coronary artery disease, according to the results of the SYNTAX trial (N. Engl. J. Med. 2009;360:961-72), it appears that CABG is being underused, the authors wrote. It seems likely that in recent years, "patients who would have been optimally treated with CABG surgery were instead treated with PCI," they noted.

To assess temporal trends in coronary revascularization procedures, the investigators examined a nationally representative sample of hospitalization claims using an Agency for Healthcare Research and Quality database. The database includes discharge data from approximately 1,000 nonfederal hospitals in 42 states, which covers 20% of U.S. hospitals and allows accurate estimates for the entire population of hospitalized patients, regardless of payer or insurance status.

Between 2001 and 2008, the total number of coronary revascularizations decreased "modestly," by approximately 15%.

There was a "substantial," statistically significant, 38% decrease in the annual rate of CABG surgery, from 1,742 per million adults in the first year of the study period to 1,081 per million in the final year. This decline was roughly linear throughout the 8-year study period, suggesting that it "was not triggered by any single event occurring during the past decade, such as the introduction of competing technologies, advances in CABG surgical techniques, publication of clinical trials, or issuance of clinical guidelines."

CABG procedures decreased across all sex, age, racial, and regional subgroups.

In contrast, the PCI rate remained fairly constant, showing a "modest" 4% decrease from 3,827 per million adults per year in the first year of the study to 3,667 in the final year.

"Projected to the entire U.S. population, these rate changes implied that 130,000 fewer CABG surgeries were performed in 2008 compared to 2001," Dr. Epstein and his colleagues noted (JAMA 2011;305:1769-76).

The data did not allow the researchers to distinguish which patients may have been more appropriate candidates for CABG than for PCI, so "it cannot be known with certainty whether physicians were increasingly substituting PCI for CABG surgery during the past decade. ... [But] our findings suggest the possibility that several thousand patients who underwent PCI in 2008 would have undergone CABG surgery had patterns of care not changed markedly," they said.

The preferences of patients were also not discernible from the data, lead investigator Dr. Peter W. Groeneveld said in an interview. "However, if patient preference [for PCI vs. CABG] was the driving factor, there would have to be some reason that PCI was even more preferable to patients in 2008 than it was in 2001. This scenario seems unlikely since the procedures haven’t changed that much," said Dr. Groeneveld, assistant professor of medicine at the University of Pennsylvania and staff physician at the Philadelphia Veterans Affairs Medical Center.

Another important finding was that during this interval, the number of hospitals providing CABG increased. Combined with the drop in the number of CABG surgeries, this resulted in a 28% decline in the median caseload per hospital, "and a substantial increase in the number of hospitals that provided fewer than 100 CABG surgeries per year."

Whether or not low-volume centers inherently have worse CABG outcomes can be debated, but either way "our findings highlight the increasing role of low-volume hospitals in the provision of CABG surgery," Dr. Epstein and his associates said.

The final trend in coronary revascularizations revealed in these data was the marked surge in PCI procedures using drug-eluting stents soon after two devices were approved by the Food and Drug Administration in 2003. By mid-2005, 90% of PCI procedures involved drug-eluting stents, reflecting "a high level of clinician enthusiasm" for the devices.

This peak was soon followed by a marked decline after the publication of safety concerns such as late in-stent thrombosis, "as well as increasing clinician awareness of the imperative for ... adherence to long-duration antiplatelet therapy." By the beginning of 2008, only 61% of PCI procedures involved placement of drug-eluting stents, but that rate increased steadily during that year, which also saw the adoption of second-generation stents that carried lower restenosis rates.

"An important implication of this volatility is that thousands of patients may have received drug-eluting stents during the peak years who would have received bare-metal stents [in later years]. Whether these patients were appropriately treated ... during these years of ‘high enthusiasm’ for drug-eluting stents is uncertain," the investigators noted.

This study was supported by the National Heart, Lung, and Blood Institute; the Agency for Healthcare Research and Quality; and the Pennsylvania Department of Health.

The rate of coronary artery bypass grafting in U.S. hospitals declined by approximately one-third between 2001 and 2008, according to an analysis of the Agency for Healthcare Research and Quality database reported in the May 4 issue of JAMA.

During the same period, the rate of percutaneous coronary interventions (PCIs) showed a far more modest decrease. "Our data imply a sizeable shift in cardiovascular clinical practice patterns away from surgical treatment toward percutaneous, catheter-based interventions," said Andrew J. Epstein, Ph.D., of the Philadelphia Veterans Affairs’ Center for Health Equity Research and Promotion and the University of Pennsylvania, and his associates.

Given that coronary artery bypass grafting remains the better choice for patients with previously untreated three-vessel or left main coronary artery disease, according to the results of the SYNTAX trial (N. Engl. J. Med. 2009;360:961-72), it appears that CABG is being underused, the authors wrote. It seems likely that in recent years, "patients who would have been optimally treated with CABG surgery were instead treated with PCI," they noted.

To assess temporal trends in coronary revascularization procedures, the investigators examined a nationally representative sample of hospitalization claims using an Agency for Healthcare Research and Quality database. The database includes discharge data from approximately 1,000 nonfederal hospitals in 42 states, which covers 20% of U.S. hospitals and allows accurate estimates for the entire population of hospitalized patients, regardless of payer or insurance status.

Between 2001 and 2008, the total number of coronary revascularizations decreased "modestly," by approximately 15%.

There was a "substantial," statistically significant, 38% decrease in the annual rate of CABG surgery, from 1,742 per million adults in the first year of the study period to 1,081 per million in the final year. This decline was roughly linear throughout the 8-year study period, suggesting that it "was not triggered by any single event occurring during the past decade, such as the introduction of competing technologies, advances in CABG surgical techniques, publication of clinical trials, or issuance of clinical guidelines."

CABG procedures decreased across all sex, age, racial, and regional subgroups.

In contrast, the PCI rate remained fairly constant, showing a "modest" 4% decrease from 3,827 per million adults per year in the first year of the study to 3,667 in the final year.

"Projected to the entire U.S. population, these rate changes implied that 130,000 fewer CABG surgeries were performed in 2008 compared to 2001," Dr. Epstein and his colleagues noted (JAMA 2011;305:1769-76).

The data did not allow the researchers to distinguish which patients may have been more appropriate candidates for CABG than for PCI, so "it cannot be known with certainty whether physicians were increasingly substituting PCI for CABG surgery during the past decade. ... [But] our findings suggest the possibility that several thousand patients who underwent PCI in 2008 would have undergone CABG surgery had patterns of care not changed markedly," they said.

The preferences of patients were also not discernible from the data, lead investigator Dr. Peter W. Groeneveld said in an interview. "However, if patient preference [for PCI vs. CABG] was the driving factor, there would have to be some reason that PCI was even more preferable to patients in 2008 than it was in 2001. This scenario seems unlikely since the procedures haven’t changed that much," said Dr. Groeneveld, assistant professor of medicine at the University of Pennsylvania and staff physician at the Philadelphia Veterans Affairs Medical Center.

Another important finding was that during this interval, the number of hospitals providing CABG increased. Combined with the drop in the number of CABG surgeries, this resulted in a 28% decline in the median caseload per hospital, "and a substantial increase in the number of hospitals that provided fewer than 100 CABG surgeries per year."

Whether or not low-volume centers inherently have worse CABG outcomes can be debated, but either way "our findings highlight the increasing role of low-volume hospitals in the provision of CABG surgery," Dr. Epstein and his associates said.

The final trend in coronary revascularizations revealed in these data was the marked surge in PCI procedures using drug-eluting stents soon after two devices were approved by the Food and Drug Administration in 2003. By mid-2005, 90% of PCI procedures involved drug-eluting stents, reflecting "a high level of clinician enthusiasm" for the devices.

This peak was soon followed by a marked decline after the publication of safety concerns such as late in-stent thrombosis, "as well as increasing clinician awareness of the imperative for ... adherence to long-duration antiplatelet therapy." By the beginning of 2008, only 61% of PCI procedures involved placement of drug-eluting stents, but that rate increased steadily during that year, which also saw the adoption of second-generation stents that carried lower restenosis rates.

"An important implication of this volatility is that thousands of patients may have received drug-eluting stents during the peak years who would have received bare-metal stents [in later years]. Whether these patients were appropriately treated ... during these years of ‘high enthusiasm’ for drug-eluting stents is uncertain," the investigators noted.

This study was supported by the National Heart, Lung, and Blood Institute; the Agency for Healthcare Research and Quality; and the Pennsylvania Department of Health.

The rate of coronary artery bypass grafting in U.S. hospitals declined by approximately one-third between 2001 and 2008, according to an analysis of the Agency for Healthcare Research and Quality database reported in the May 4 issue of JAMA.

During the same period, the rate of percutaneous coronary interventions (PCIs) showed a far more modest decrease. "Our data imply a sizeable shift in cardiovascular clinical practice patterns away from surgical treatment toward percutaneous, catheter-based interventions," said Andrew J. Epstein, Ph.D., of the Philadelphia Veterans Affairs’ Center for Health Equity Research and Promotion and the University of Pennsylvania, and his associates.

Given that coronary artery bypass grafting remains the better choice for patients with previously untreated three-vessel or left main coronary artery disease, according to the results of the SYNTAX trial (N. Engl. J. Med. 2009;360:961-72), it appears that CABG is being underused, the authors wrote. It seems likely that in recent years, "patients who would have been optimally treated with CABG surgery were instead treated with PCI," they noted.

To assess temporal trends in coronary revascularization procedures, the investigators examined a nationally representative sample of hospitalization claims using an Agency for Healthcare Research and Quality database. The database includes discharge data from approximately 1,000 nonfederal hospitals in 42 states, which covers 20% of U.S. hospitals and allows accurate estimates for the entire population of hospitalized patients, regardless of payer or insurance status.

Between 2001 and 2008, the total number of coronary revascularizations decreased "modestly," by approximately 15%.

There was a "substantial," statistically significant, 38% decrease in the annual rate of CABG surgery, from 1,742 per million adults in the first year of the study period to 1,081 per million in the final year. This decline was roughly linear throughout the 8-year study period, suggesting that it "was not triggered by any single event occurring during the past decade, such as the introduction of competing technologies, advances in CABG surgical techniques, publication of clinical trials, or issuance of clinical guidelines."

CABG procedures decreased across all sex, age, racial, and regional subgroups.

In contrast, the PCI rate remained fairly constant, showing a "modest" 4% decrease from 3,827 per million adults per year in the first year of the study to 3,667 in the final year.

"Projected to the entire U.S. population, these rate changes implied that 130,000 fewer CABG surgeries were performed in 2008 compared to 2001," Dr. Epstein and his colleagues noted (JAMA 2011;305:1769-76).

The data did not allow the researchers to distinguish which patients may have been more appropriate candidates for CABG than for PCI, so "it cannot be known with certainty whether physicians were increasingly substituting PCI for CABG surgery during the past decade. ... [But] our findings suggest the possibility that several thousand patients who underwent PCI in 2008 would have undergone CABG surgery had patterns of care not changed markedly," they said.

The preferences of patients were also not discernible from the data, lead investigator Dr. Peter W. Groeneveld said in an interview. "However, if patient preference [for PCI vs. CABG] was the driving factor, there would have to be some reason that PCI was even more preferable to patients in 2008 than it was in 2001. This scenario seems unlikely since the procedures haven’t changed that much," said Dr. Groeneveld, assistant professor of medicine at the University of Pennsylvania and staff physician at the Philadelphia Veterans Affairs Medical Center.

Another important finding was that during this interval, the number of hospitals providing CABG increased. Combined with the drop in the number of CABG surgeries, this resulted in a 28% decline in the median caseload per hospital, "and a substantial increase in the number of hospitals that provided fewer than 100 CABG surgeries per year."

Whether or not low-volume centers inherently have worse CABG outcomes can be debated, but either way "our findings highlight the increasing role of low-volume hospitals in the provision of CABG surgery," Dr. Epstein and his associates said.

The final trend in coronary revascularizations revealed in these data was the marked surge in PCI procedures using drug-eluting stents soon after two devices were approved by the Food and Drug Administration in 2003. By mid-2005, 90% of PCI procedures involved drug-eluting stents, reflecting "a high level of clinician enthusiasm" for the devices.

This peak was soon followed by a marked decline after the publication of safety concerns such as late in-stent thrombosis, "as well as increasing clinician awareness of the imperative for ... adherence to long-duration antiplatelet therapy." By the beginning of 2008, only 61% of PCI procedures involved placement of drug-eluting stents, but that rate increased steadily during that year, which also saw the adoption of second-generation stents that carried lower restenosis rates.

"An important implication of this volatility is that thousands of patients may have received drug-eluting stents during the peak years who would have received bare-metal stents [in later years]. Whether these patients were appropriately treated ... during these years of ‘high enthusiasm’ for drug-eluting stents is uncertain," the investigators noted.

This study was supported by the National Heart, Lung, and Blood Institute; the Agency for Healthcare Research and Quality; and the Pennsylvania Department of Health.

The rate of coronary artery bypass grafting in U.S. hospitals declined by approximately one-third between 2001 and 2008, according to an analysis of the Agency for Healthcare Research and Quality database reported in the May 4 issue of JAMA.

During the same period, the rate of percutaneous coronary interventions (PCIs) showed a far more modest decrease. "Our data imply a sizeable shift in cardiovascular clinical practice patterns away from surgical treatment toward percutaneous, catheter-based interventions," said Andrew J. Epstein, Ph.D., of the Philadelphia Veterans Affairs’ Center for Health Equity Research and Promotion and the University of Pennsylvania, and his associates.

Given that coronary artery bypass grafting remains the better choice for patients with previously untreated three-vessel or left main coronary artery disease, according to the results of the SYNTAX trial (N. Engl. J. Med. 2009;360:961-72), it appears that CABG is being underused, the authors wrote. It seems likely that in recent years, "patients who would have been optimally treated with CABG surgery were instead treated with PCI," they noted.

To assess temporal trends in coronary revascularization procedures, the investigators examined a nationally representative sample of hospitalization claims using an Agency for Healthcare Research and Quality database. The database includes discharge data from approximately 1,000 nonfederal hospitals in 42 states, which covers 20% of U.S. hospitals and allows accurate estimates for the entire population of hospitalized patients, regardless of payer or insurance status.

Between 2001 and 2008, the total number of coronary revascularizations decreased "modestly," by approximately 15%.

There was a "substantial," statistically significant, 38% decrease in the annual rate of CABG surgery, from 1,742 per million adults in the first year of the study period to 1,081 per million in the final year. This decline was roughly linear throughout the 8-year study period, suggesting that it "was not triggered by any single event occurring during the past decade, such as the introduction of competing technologies, advances in CABG surgical techniques, publication of clinical trials, or issuance of clinical guidelines."

CABG procedures decreased across all sex, age, racial, and regional subgroups.

In contrast, the PCI rate remained fairly constant, showing a "modest" 4% decrease from 3,827 per million adults per year in the first year of the study to 3,667 in the final year.

"Projected to the entire U.S. population, these rate changes implied that 130,000 fewer CABG surgeries were performed in 2008 compared to 2001," Dr. Epstein and his colleagues noted (JAMA 2011;305:1769-76).

The data did not allow the researchers to distinguish which patients may have been more appropriate candidates for CABG than for PCI, so "it cannot be known with certainty whether physicians were increasingly substituting PCI for CABG surgery during the past decade. ... [But] our findings suggest the possibility that several thousand patients who underwent PCI in 2008 would have undergone CABG surgery had patterns of care not changed markedly," they said.

The preferences of patients were also not discernible from the data, lead investigator Dr. Peter W. Groeneveld said in an interview. "However, if patient preference [for PCI vs. CABG] was the driving factor, there would have to be some reason that PCI was even more preferable to patients in 2008 than it was in 2001. This scenario seems unlikely since the procedures haven’t changed that much," said Dr. Groeneveld, assistant professor of medicine at the University of Pennsylvania and staff physician at the Philadelphia Veterans Affairs Medical Center.

Another important finding was that during this interval, the number of hospitals providing CABG increased. Combined with the drop in the number of CABG surgeries, this resulted in a 28% decline in the median caseload per hospital, "and a substantial increase in the number of hospitals that provided fewer than 100 CABG surgeries per year."

Whether or not low-volume centers inherently have worse CABG outcomes can be debated, but either way "our findings highlight the increasing role of low-volume hospitals in the provision of CABG surgery," Dr. Epstein and his associates said.

The final trend in coronary revascularizations revealed in these data was the marked surge in PCI procedures using drug-eluting stents soon after two devices were approved by the Food and Drug Administration in 2003. By mid-2005, 90% of PCI procedures involved drug-eluting stents, reflecting "a high level of clinician enthusiasm" for the devices.

This peak was soon followed by a marked decline after the publication of safety concerns such as late in-stent thrombosis, "as well as increasing clinician awareness of the imperative for ... adherence to long-duration antiplatelet therapy." By the beginning of 2008, only 61% of PCI procedures involved placement of drug-eluting stents, but that rate increased steadily during that year, which also saw the adoption of second-generation stents that carried lower restenosis rates.

"An important implication of this volatility is that thousands of patients may have received drug-eluting stents during the peak years who would have received bare-metal stents [in later years]. Whether these patients were appropriately treated ... during these years of ‘high enthusiasm’ for drug-eluting stents is uncertain," the investigators noted.

This study was supported by the National Heart, Lung, and Blood Institute; the Agency for Healthcare Research and Quality; and the Pennsylvania Department of Health.

The rate of coronary artery bypass grafting in U.S. hospitals declined by approximately one-third between 2001 and 2008, according to an analysis of the Agency for Healthcare Research and Quality database reported in the May 4 issue of JAMA.

During the same period, the rate of percutaneous coronary interventions (PCIs) showed a far more modest decrease. "Our data imply a sizeable shift in cardiovascular clinical practice patterns away from surgical treatment toward percutaneous, catheter-based interventions," said Andrew J. Epstein, Ph.D., of the Philadelphia Veterans Affairs’ Center for Health Equity Research and Promotion and the University of Pennsylvania, and his associates.

Given that coronary artery bypass grafting remains the better choice for patients with previously untreated three-vessel or left main coronary artery disease, according to the results of the SYNTAX trial (N. Engl. J. Med. 2009;360:961-72), it appears that CABG is being underused, the authors wrote. It seems likely that in recent years, "patients who would have been optimally treated with CABG surgery were instead treated with PCI," they noted.

To assess temporal trends in coronary revascularization procedures, the investigators examined a nationally representative sample of hospitalization claims using an Agency for Healthcare Research and Quality database. The database includes discharge data from approximately 1,000 nonfederal hospitals in 42 states, which covers 20% of U.S. hospitals and allows accurate estimates for the entire population of hospitalized patients, regardless of payer or insurance status.

Between 2001 and 2008, the total number of coronary revascularizations decreased "modestly," by approximately 15%.

There was a "substantial," statistically significant, 38% decrease in the annual rate of CABG surgery, from 1,742 per million adults in the first year of the study period to 1,081 per million in the final year. This decline was roughly linear throughout the 8-year study period, suggesting that it "was not triggered by any single event occurring during the past decade, such as the introduction of competing technologies, advances in CABG surgical techniques, publication of clinical trials, or issuance of clinical guidelines."

CABG procedures decreased across all sex, age, racial, and regional subgroups.

In contrast, the PCI rate remained fairly constant, showing a "modest" 4% decrease from 3,827 per million adults per year in the first year of the study to 3,667 in the final year.

"Projected to the entire U.S. population, these rate changes implied that 130,000 fewer CABG surgeries were performed in 2008 compared to 2001," Dr. Epstein and his colleagues noted (JAMA 2011;305:1769-76).

The data did not allow the researchers to distinguish which patients may have been more appropriate candidates for CABG than for PCI, so "it cannot be known with certainty whether physicians were increasingly substituting PCI for CABG surgery during the past decade. ... [But] our findings suggest the possibility that several thousand patients who underwent PCI in 2008 would have undergone CABG surgery had patterns of care not changed markedly," they said.

The preferences of patients were also not discernible from the data, lead investigator Dr. Peter W. Groeneveld said in an interview. "However, if patient preference [for PCI vs. CABG] was the driving factor, there would have to be some reason that PCI was even more preferable to patients in 2008 than it was in 2001. This scenario seems unlikely since the procedures haven’t changed that much," said Dr. Groeneveld, assistant professor of medicine at the University of Pennsylvania and staff physician at the Philadelphia Veterans Affairs Medical Center.

Another important finding was that during this interval, the number of hospitals providing CABG increased. Combined with the drop in the number of CABG surgeries, this resulted in a 28% decline in the median caseload per hospital, "and a substantial increase in the number of hospitals that provided fewer than 100 CABG surgeries per year."

Whether or not low-volume centers inherently have worse CABG outcomes can be debated, but either way "our findings highlight the increasing role of low-volume hospitals in the provision of CABG surgery," Dr. Epstein and his associates said.

The final trend in coronary revascularizations revealed in these data was the marked surge in PCI procedures using drug-eluting stents soon after two devices were approved by the Food and Drug Administration in 2003. By mid-2005, 90% of PCI procedures involved drug-eluting stents, reflecting "a high level of clinician enthusiasm" for the devices.

This peak was soon followed by a marked decline after the publication of safety concerns such as late in-stent thrombosis, "as well as increasing clinician awareness of the imperative for ... adherence to long-duration antiplatelet therapy." By the beginning of 2008, only 61% of PCI procedures involved placement of drug-eluting stents, but that rate increased steadily during that year, which also saw the adoption of second-generation stents that carried lower restenosis rates.

"An important implication of this volatility is that thousands of patients may have received drug-eluting stents during the peak years who would have received bare-metal stents [in later years]. Whether these patients were appropriately treated ... during these years of ‘high enthusiasm’ for drug-eluting stents is uncertain," the investigators noted.

This study was supported by the National Heart, Lung, and Blood Institute; the Agency for Healthcare Research and Quality; and the Pennsylvania Department of Health.

The rate of coronary artery bypass grafting in U.S. hospitals declined by approximately one-third between 2001 and 2008, according to an analysis of the Agency for Healthcare Research and Quality database reported in the May 4 issue of JAMA.

During the same period, the rate of percutaneous coronary interventions (PCIs) showed a far more modest decrease. "Our data imply a sizeable shift in cardiovascular clinical practice patterns away from surgical treatment toward percutaneous, catheter-based interventions," said Andrew J. Epstein, Ph.D., of the Philadelphia Veterans Affairs’ Center for Health Equity Research and Promotion and the University of Pennsylvania, and his associates.

Given that coronary artery bypass grafting remains the better choice for patients with previously untreated three-vessel or left main coronary artery disease, according to the results of the SYNTAX trial (N. Engl. J. Med. 2009;360:961-72), it appears that CABG is being underused, the authors wrote. It seems likely that in recent years, "patients who would have been optimally treated with CABG surgery were instead treated with PCI," they noted.

To assess temporal trends in coronary revascularization procedures, the investigators examined a nationally representative sample of hospitalization claims using an Agency for Healthcare Research and Quality database. The database includes discharge data from approximately 1,000 nonfederal hospitals in 42 states, which covers 20% of U.S. hospitals and allows accurate estimates for the entire population of hospitalized patients, regardless of payer or insurance status.

Between 2001 and 2008, the total number of coronary revascularizations decreased "modestly," by approximately 15%.

There was a "substantial," statistically significant, 38% decrease in the annual rate of CABG surgery, from 1,742 per million adults in the first year of the study period to 1,081 per million in the final year. This decline was roughly linear throughout the 8-year study period, suggesting that it "was not triggered by any single event occurring during the past decade, such as the introduction of competing technologies, advances in CABG surgical techniques, publication of clinical trials, or issuance of clinical guidelines."

CABG procedures decreased across all sex, age, racial, and regional subgroups.

In contrast, the PCI rate remained fairly constant, showing a "modest" 4% decrease from 3,827 per million adults per year in the first year of the study to 3,667 in the final year.

"Projected to the entire U.S. population, these rate changes implied that 130,000 fewer CABG surgeries were performed in 2008 compared to 2001," Dr. Epstein and his colleagues noted (JAMA 2011;305:1769-76).

The data did not allow the researchers to distinguish which patients may have been more appropriate candidates for CABG than for PCI, so "it cannot be known with certainty whether physicians were increasingly substituting PCI for CABG surgery during the past decade. ... [But] our findings suggest the possibility that several thousand patients who underwent PCI in 2008 would have undergone CABG surgery had patterns of care not changed markedly," they said.

The preferences of patients were also not discernible from the data, lead investigator Dr. Peter W. Groeneveld said in an interview. "However, if patient preference [for PCI vs. CABG] was the driving factor, there would have to be some reason that PCI was even more preferable to patients in 2008 than it was in 2001. This scenario seems unlikely since the procedures haven’t changed that much," said Dr. Groeneveld, assistant professor of medicine at the University of Pennsylvania and staff physician at the Philadelphia Veterans Affairs Medical Center.

Another important finding was that during this interval, the number of hospitals providing CABG increased. Combined with the drop in the number of CABG surgeries, this resulted in a 28% decline in the median caseload per hospital, "and a substantial increase in the number of hospitals that provided fewer than 100 CABG surgeries per year."

Whether or not low-volume centers inherently have worse CABG outcomes can be debated, but either way "our findings highlight the increasing role of low-volume hospitals in the provision of CABG surgery," Dr. Epstein and his associates said.

The final trend in coronary revascularizations revealed in these data was the marked surge in PCI procedures using drug-eluting stents soon after two devices were approved by the Food and Drug Administration in 2003. By mid-2005, 90% of PCI procedures involved drug-eluting stents, reflecting "a high level of clinician enthusiasm" for the devices.

This peak was soon followed by a marked decline after the publication of safety concerns such as late in-stent thrombosis, "as well as increasing clinician awareness of the imperative for ... adherence to long-duration antiplatelet therapy." By the beginning of 2008, only 61% of PCI procedures involved placement of drug-eluting stents, but that rate increased steadily during that year, which also saw the adoption of second-generation stents that carried lower restenosis rates.

"An important implication of this volatility is that thousands of patients may have received drug-eluting stents during the peak years who would have received bare-metal stents [in later years]. Whether these patients were appropriately treated ... during these years of ‘high enthusiasm’ for drug-eluting stents is uncertain," the investigators noted.

This study was supported by the National Heart, Lung, and Blood Institute; the Agency for Healthcare Research and Quality; and the Pennsylvania Department of Health.

Structured exercise with aerobic, resistance, or combined training was associated with a 0.67% decrease in hemoglobin A_1c level among patients with type 2 diabetes, according to a meta-analysis in the May 4 issue of JAMA.

This compares favorably with the HbA_1c reductions reported for combination treatment with noninsulin antidiabetic drugs and maximal doses of metformin, said Daniel Umpierre of the Hospital de Clinicas de Porto Alegre (Brazil) and his associates.

The investigators performed a meta-analysis of 47 randomized controlled trials that assessed the effects of 12 weeks or more of structured aerobic exercise training (848 subjects), structured resistance exercise training (261), combined aerobic and resistance training (404), or unstructured physical activity (7,025) on HbA_1c levels.

Structured exercise training was defined as an intervention in which patients engaged in a planned, individualized, and supervised exercise program.

"The general quality of the studies was low, reflecting increased risk of bias in some studies," the investigators noted.

Eighteen studies demonstrated that structured aerobic exercise training was associated with an absolute reduction of 0.73% in HbA_1c level. Four studies showed that structured resistance exercise training was associated with an absolute reduction of 0.57%. And seven studies showed that combined aerobic plus resistance exercise training was associated with an absolute reduction of 0.51%.

These benefits were most marked when the exercise was performed for 150 min/wk or more (absolute reduction of 0.89% in HbA_1c), and less so when it was performed less often (absolute reduction of 0.36% in HbA_1c). Current guidelines recommend an exercise duration of at least 150 min/wk, Mr. Umpierre and his colleagues said (JAMA 2011;305:1790-9).

In contrast, 24 studies of physical activity demonstrated that it was associated with an absolute reduction of 0.43% in HbA_1c. However, physical activity alone did not reduce HbA_1c. It was effective only when combined with dietary advice, as shown in 12 studies in which HbA_1c level declined by 0.58%.

"To our knowledge, this is the first systematic review to assess the association between physical activity advice interventions and glycemic control," they noted.

Mr. Umpierre’s associates reported ties to Bristol-Myers Squibb, GlaxoSmithKline, Merck Sharpe & Dohme, Servier, Abbott, Aventis, Bioassist, and Boehringer Ingelheim.

Structured exercise with aerobic, resistance, or combined training was associated with a 0.67% decrease in hemoglobin A_1c level among patients with type 2 diabetes, according to a meta-analysis in the May 4 issue of JAMA.

This compares favorably with the HbA_1c reductions reported for combination treatment with noninsulin antidiabetic drugs and maximal doses of metformin, said Daniel Umpierre of the Hospital de Clinicas de Porto Alegre (Brazil) and his associates.

The investigators performed a meta-analysis of 47 randomized controlled trials that assessed the effects of 12 weeks or more of structured aerobic exercise training (848 subjects), structured resistance exercise training (261), combined aerobic and resistance training (404), or unstructured physical activity (7,025) on HbA_1c levels.

Structured exercise training was defined as an intervention in which patients engaged in a planned, individualized, and supervised exercise program.

"The general quality of the studies was low, reflecting increased risk of bias in some studies," the investigators noted.

Eighteen studies demonstrated that structured aerobic exercise training was associated with an absolute reduction of 0.73% in HbA_1c level. Four studies showed that structured resistance exercise training was associated with an absolute reduction of 0.57%. And seven studies showed that combined aerobic plus resistance exercise training was associated with an absolute reduction of 0.51%.

These benefits were most marked when the exercise was performed for 150 min/wk or more (absolute reduction of 0.89% in HbA_1c), and less so when it was performed less often (absolute reduction of 0.36% in HbA_1c). Current guidelines recommend an exercise duration of at least 150 min/wk, Mr. Umpierre and his colleagues said (JAMA 2011;305:1790-9).

In contrast, 24 studies of physical activity demonstrated that it was associated with an absolute reduction of 0.43% in HbA_1c. However, physical activity alone did not reduce HbA_1c. It was effective only when combined with dietary advice, as shown in 12 studies in which HbA_1c level declined by 0.58%.

"To our knowledge, this is the first systematic review to assess the association between physical activity advice interventions and glycemic control," they noted.

Mr. Umpierre’s associates reported ties to Bristol-Myers Squibb, GlaxoSmithKline, Merck Sharpe & Dohme, Servier, Abbott, Aventis, Bioassist, and Boehringer Ingelheim.

Structured exercise with aerobic, resistance, or combined training was associated with a 0.67% decrease in hemoglobin A_1c level among patients with type 2 diabetes, according to a meta-analysis in the May 4 issue of JAMA.

This compares favorably with the HbA_1c reductions reported for combination treatment with noninsulin antidiabetic drugs and maximal doses of metformin, said Daniel Umpierre of the Hospital de Clinicas de Porto Alegre (Brazil) and his associates.

The investigators performed a meta-analysis of 47 randomized controlled trials that assessed the effects of 12 weeks or more of structured aerobic exercise training (848 subjects), structured resistance exercise training (261), combined aerobic and resistance training (404), or unstructured physical activity (7,025) on HbA_1c levels.

Structured exercise training was defined as an intervention in which patients engaged in a planned, individualized, and supervised exercise program.

"The general quality of the studies was low, reflecting increased risk of bias in some studies," the investigators noted.

Eighteen studies demonstrated that structured aerobic exercise training was associated with an absolute reduction of 0.73% in HbA_1c level. Four studies showed that structured resistance exercise training was associated with an absolute reduction of 0.57%. And seven studies showed that combined aerobic plus resistance exercise training was associated with an absolute reduction of 0.51%.

These benefits were most marked when the exercise was performed for 150 min/wk or more (absolute reduction of 0.89% in HbA_1c), and less so when it was performed less often (absolute reduction of 0.36% in HbA_1c). Current guidelines recommend an exercise duration of at least 150 min/wk, Mr. Umpierre and his colleagues said (JAMA 2011;305:1790-9).

In contrast, 24 studies of physical activity demonstrated that it was associated with an absolute reduction of 0.43% in HbA_1c. However, physical activity alone did not reduce HbA_1c. It was effective only when combined with dietary advice, as shown in 12 studies in which HbA_1c level declined by 0.58%.

"To our knowledge, this is the first systematic review to assess the association between physical activity advice interventions and glycemic control," they noted.

Mr. Umpierre’s associates reported ties to Bristol-Myers Squibb, GlaxoSmithKline, Merck Sharpe & Dohme, Servier, Abbott, Aventis, Bioassist, and Boehringer Ingelheim.

Structured exercise with aerobic, resistance, or combined training was associated with a 0.67% decrease in hemoglobin A_1c level among patients with type 2 diabetes, according to a meta-analysis in the May 4 issue of JAMA.

This compares favorably with the HbA_1c reductions reported for combination treatment with noninsulin antidiabetic drugs and maximal doses of metformin, said Daniel Umpierre of the Hospital de Clinicas de Porto Alegre (Brazil) and his associates.

The investigators performed a meta-analysis of 47 randomized controlled trials that assessed the effects of 12 weeks or more of structured aerobic exercise training (848 subjects), structured resistance exercise training (261), combined aerobic and resistance training (404), or unstructured physical activity (7,025) on HbA_1c levels.

Structured exercise training was defined as an intervention in which patients engaged in a planned, individualized, and supervised exercise program.

"The general quality of the studies was low, reflecting increased risk of bias in some studies," the investigators noted.

Eighteen studies demonstrated that structured aerobic exercise training was associated with an absolute reduction of 0.73% in HbA_1c level. Four studies showed that structured resistance exercise training was associated with an absolute reduction of 0.57%. And seven studies showed that combined aerobic plus resistance exercise training was associated with an absolute reduction of 0.51%.

These benefits were most marked when the exercise was performed for 150 min/wk or more (absolute reduction of 0.89% in HbA_1c), and less so when it was performed less often (absolute reduction of 0.36% in HbA_1c). Current guidelines recommend an exercise duration of at least 150 min/wk, Mr. Umpierre and his colleagues said (JAMA 2011;305:1790-9).

In contrast, 24 studies of physical activity demonstrated that it was associated with an absolute reduction of 0.43% in HbA_1c. However, physical activity alone did not reduce HbA_1c. It was effective only when combined with dietary advice, as shown in 12 studies in which HbA_1c level declined by 0.58%.

"To our knowledge, this is the first systematic review to assess the association between physical activity advice interventions and glycemic control," they noted.

Mr. Umpierre’s associates reported ties to Bristol-Myers Squibb, GlaxoSmithKline, Merck Sharpe & Dohme, Servier, Abbott, Aventis, Bioassist, and Boehringer Ingelheim.

Structured exercise with aerobic, resistance, or combined training was associated with a 0.67% decrease in hemoglobin A_1c level among patients with type 2 diabetes, according to a meta-analysis in the May 4 issue of JAMA.

This compares favorably with the HbA_1c reductions reported for combination treatment with noninsulin antidiabetic drugs and maximal doses of metformin, said Daniel Umpierre of the Hospital de Clinicas de Porto Alegre (Brazil) and his associates.

The investigators performed a meta-analysis of 47 randomized controlled trials that assessed the effects of 12 weeks or more of structured aerobic exercise training (848 subjects), structured resistance exercise training (261), combined aerobic and resistance training (404), or unstructured physical activity (7,025) on HbA_1c levels.

Structured exercise training was defined as an intervention in which patients engaged in a planned, individualized, and supervised exercise program.

"The general quality of the studies was low, reflecting increased risk of bias in some studies," the investigators noted.

Eighteen studies demonstrated that structured aerobic exercise training was associated with an absolute reduction of 0.73% in HbA_1c level. Four studies showed that structured resistance exercise training was associated with an absolute reduction of 0.57%. And seven studies showed that combined aerobic plus resistance exercise training was associated with an absolute reduction of 0.51%.

These benefits were most marked when the exercise was performed for 150 min/wk or more (absolute reduction of 0.89% in HbA_1c), and less so when it was performed less often (absolute reduction of 0.36% in HbA_1c). Current guidelines recommend an exercise duration of at least 150 min/wk, Mr. Umpierre and his colleagues said (JAMA 2011;305:1790-9).

In contrast, 24 studies of physical activity demonstrated that it was associated with an absolute reduction of 0.43% in HbA_1c. However, physical activity alone did not reduce HbA_1c. It was effective only when combined with dietary advice, as shown in 12 studies in which HbA_1c level declined by 0.58%.

"To our knowledge, this is the first systematic review to assess the association between physical activity advice interventions and glycemic control," they noted.

Mr. Umpierre’s associates reported ties to Bristol-Myers Squibb, GlaxoSmithKline, Merck Sharpe & Dohme, Servier, Abbott, Aventis, Bioassist, and Boehringer Ingelheim.

Structured exercise with aerobic, resistance, or combined training was associated with a 0.67% decrease in hemoglobin A_1c level among patients with type 2 diabetes, according to a meta-analysis in the May 4 issue of JAMA.

This compares favorably with the HbA_1c reductions reported for combination treatment with noninsulin antidiabetic drugs and maximal doses of metformin, said Daniel Umpierre of the Hospital de Clinicas de Porto Alegre (Brazil) and his associates.

The investigators performed a meta-analysis of 47 randomized controlled trials that assessed the effects of 12 weeks or more of structured aerobic exercise training (848 subjects), structured resistance exercise training (261), combined aerobic and resistance training (404), or unstructured physical activity (7,025) on HbA_1c levels.

Structured exercise training was defined as an intervention in which patients engaged in a planned, individualized, and supervised exercise program.

"The general quality of the studies was low, reflecting increased risk of bias in some studies," the investigators noted.

Eighteen studies demonstrated that structured aerobic exercise training was associated with an absolute reduction of 0.73% in HbA_1c level. Four studies showed that structured resistance exercise training was associated with an absolute reduction of 0.57%. And seven studies showed that combined aerobic plus resistance exercise training was associated with an absolute reduction of 0.51%.

These benefits were most marked when the exercise was performed for 150 min/wk or more (absolute reduction of 0.89% in HbA_1c), and less so when it was performed less often (absolute reduction of 0.36% in HbA_1c). Current guidelines recommend an exercise duration of at least 150 min/wk, Mr. Umpierre and his colleagues said (JAMA 2011;305:1790-9).

In contrast, 24 studies of physical activity demonstrated that it was associated with an absolute reduction of 0.43% in HbA_1c. However, physical activity alone did not reduce HbA_1c. It was effective only when combined with dietary advice, as shown in 12 studies in which HbA_1c level declined by 0.58%.

"To our knowledge, this is the first systematic review to assess the association between physical activity advice interventions and glycemic control," they noted.

Mr. Umpierre’s associates reported ties to Bristol-Myers Squibb, GlaxoSmithKline, Merck Sharpe & Dohme, Servier, Abbott, Aventis, Bioassist, and Boehringer Ingelheim.

A children’s hospital with no rapid response team showed the same reductions in mortality during the same time frames as did hospitals that attributed their drops in mortality to their rapid response teams, according to a report in the May issue of the Archives of Pediatrics and Adolescent Medicine.

The "before-and-after" design of studies that purport to show the benefits of rapid response teams are inherently flawed. The fact that their own such before-and-after study reached the same conclusion at a hospital with no rapid response team shows that evidence supporting such teams is open to question, said Dr. Ari R. Joffe of the University of Alberta and Stollery Children’s Hospital, Edmonton, and his associates.

Pediatric rapid response teams, also known as medical emergency or critical care outreach teams, are groups of experts always ready to intervene when a cardiopulmonary arrest seems imminent and to respond to when one occurs. They have been touted as a means to reduce mortality from in-hospital cardiopulmonary arrest.

But the only studies that support this contention have relied on "before-and-after" designs in which present-day cohorts were compared with historical controls who were treated before the rapid response teams were implemented. This design fails to account for many variables known to affect mortality, such as temporal trends, differences in case mix, and differences in severity of illness.

To test the hypothesis that favorable study results actually were due to flaws in study design, Dr. Joffe and his colleagues reviewed mortality patterns at their own hospital, which has no rapid response team, during the same before-and-after periods.

They found a highly significant reduction in mortality at their hospital during the same intervals in which two studies found similar reductions and attributed them to their rapid response teams.

Moreover, Dr. Joffe and his associates found no reduction in mortality at their hospital during other intervals in which three other studies found no such reductions.

In addition, "when we divided our data into equal 4- and 5-year periods, there was a highly significant reduction in hospital mortality in the ‘after’ periods compared with the ‘before’ periods at our hospital."

And the results were the same in a year-by-year logistic regression analysis of the data at their hospital.

"If we had implemented a [rapid response team], we would likely have misattributed the reduction in hospital mortality over time to this intervention," the researchers said.

"These results call into question the strength of the pediatric medical emergency team data from the cohort studies with historical controls," they noted (Arch. Ped. Adolesc. Med. 2011;165:419-23).

The studies that purport to show the benefits of rapid response teams also were flawed in other ways. For example, hospitals each used different criteria for calling the rapid response team, and the rates of making such calls varied markedly between hospitals, but such differences were not accounted for in analyses of the data.

No financial conflicts of interest were reported in Dr. Joffe’s report.

A children’s hospital with no rapid response team showed the same reductions in mortality during the same time frames as did hospitals that attributed their drops in mortality to their rapid response teams, according to a report in the May issue of the Archives of Pediatrics and Adolescent Medicine.

The "before-and-after" design of studies that purport to show the benefits of rapid response teams are inherently flawed. The fact that their own such before-and-after study reached the same conclusion at a hospital with no rapid response team shows that evidence supporting such teams is open to question, said Dr. Ari R. Joffe of the University of Alberta and Stollery Children’s Hospital, Edmonton, and his associates.

Pediatric rapid response teams, also known as medical emergency or critical care outreach teams, are groups of experts always ready to intervene when a cardiopulmonary arrest seems imminent and to respond to when one occurs. They have been touted as a means to reduce mortality from in-hospital cardiopulmonary arrest.

But the only studies that support this contention have relied on "before-and-after" designs in which present-day cohorts were compared with historical controls who were treated before the rapid response teams were implemented. This design fails to account for many variables known to affect mortality, such as temporal trends, differences in case mix, and differences in severity of illness.

To test the hypothesis that favorable study results actually were due to flaws in study design, Dr. Joffe and his colleagues reviewed mortality patterns at their own hospital, which has no rapid response team, during the same before-and-after periods.

They found a highly significant reduction in mortality at their hospital during the same intervals in which two studies found similar reductions and attributed them to their rapid response teams.

Moreover, Dr. Joffe and his associates found no reduction in mortality at their hospital during other intervals in which three other studies found no such reductions.

In addition, "when we divided our data into equal 4- and 5-year periods, there was a highly significant reduction in hospital mortality in the ‘after’ periods compared with the ‘before’ periods at our hospital."

And the results were the same in a year-by-year logistic regression analysis of the data at their hospital.

"If we had implemented a [rapid response team], we would likely have misattributed the reduction in hospital mortality over time to this intervention," the researchers said.

"These results call into question the strength of the pediatric medical emergency team data from the cohort studies with historical controls," they noted (Arch. Ped. Adolesc. Med. 2011;165:419-23).

The studies that purport to show the benefits of rapid response teams also were flawed in other ways. For example, hospitals each used different criteria for calling the rapid response team, and the rates of making such calls varied markedly between hospitals, but such differences were not accounted for in analyses of the data.

No financial conflicts of interest were reported in Dr. Joffe’s report.

A children’s hospital with no rapid response team showed the same reductions in mortality during the same time frames as did hospitals that attributed their drops in mortality to their rapid response teams, according to a report in the May issue of the Archives of Pediatrics and Adolescent Medicine.

The "before-and-after" design of studies that purport to show the benefits of rapid response teams are inherently flawed. The fact that their own such before-and-after study reached the same conclusion at a hospital with no rapid response team shows that evidence supporting such teams is open to question, said Dr. Ari R. Joffe of the University of Alberta and Stollery Children’s Hospital, Edmonton, and his associates.

Pediatric rapid response teams, also known as medical emergency or critical care outreach teams, are groups of experts always ready to intervene when a cardiopulmonary arrest seems imminent and to respond to when one occurs. They have been touted as a means to reduce mortality from in-hospital cardiopulmonary arrest.

But the only studies that support this contention have relied on "before-and-after" designs in which present-day cohorts were compared with historical controls who were treated before the rapid response teams were implemented. This design fails to account for many variables known to affect mortality, such as temporal trends, differences in case mix, and differences in severity of illness.

To test the hypothesis that favorable study results actually were due to flaws in study design, Dr. Joffe and his colleagues reviewed mortality patterns at their own hospital, which has no rapid response team, during the same before-and-after periods.

They found a highly significant reduction in mortality at their hospital during the same intervals in which two studies found similar reductions and attributed them to their rapid response teams.

Moreover, Dr. Joffe and his associates found no reduction in mortality at their hospital during other intervals in which three other studies found no such reductions.

In addition, "when we divided our data into equal 4- and 5-year periods, there was a highly significant reduction in hospital mortality in the ‘after’ periods compared with the ‘before’ periods at our hospital."

And the results were the same in a year-by-year logistic regression analysis of the data at their hospital.

"If we had implemented a [rapid response team], we would likely have misattributed the reduction in hospital mortality over time to this intervention," the researchers said.

"These results call into question the strength of the pediatric medical emergency team data from the cohort studies with historical controls," they noted (Arch. Ped. Adolesc. Med. 2011;165:419-23).

The studies that purport to show the benefits of rapid response teams also were flawed in other ways. For example, hospitals each used different criteria for calling the rapid response team, and the rates of making such calls varied markedly between hospitals, but such differences were not accounted for in analyses of the data.

No financial conflicts of interest were reported in Dr. Joffe’s report.

A children’s hospital with no rapid response team showed the same reductions in mortality during the same time frames as did hospitals that attributed their drops in mortality to their rapid response teams, according to a report in the May issue of the Archives of Pediatrics and Adolescent Medicine.

The "before-and-after" design of studies that purport to show the benefits of rapid response teams are inherently flawed. The fact that their own such before-and-after study reached the same conclusion at a hospital with no rapid response team shows that evidence supporting such teams is open to question, said Dr. Ari R. Joffe of the University of Alberta and Stollery Children’s Hospital, Edmonton, and his associates.

Pediatric rapid response teams, also known as medical emergency or critical care outreach teams, are groups of experts always ready to intervene when a cardiopulmonary arrest seems imminent and to respond to when one occurs. They have been touted as a means to reduce mortality from in-hospital cardiopulmonary arrest.

But the only studies that support this contention have relied on "before-and-after" designs in which present-day cohorts were compared with historical controls who were treated before the rapid response teams were implemented. This design fails to account for many variables known to affect mortality, such as temporal trends, differences in case mix, and differences in severity of illness.

To test the hypothesis that favorable study results actually were due to flaws in study design, Dr. Joffe and his colleagues reviewed mortality patterns at their own hospital, which has no rapid response team, during the same before-and-after periods.

They found a highly significant reduction in mortality at their hospital during the same intervals in which two studies found similar reductions and attributed them to their rapid response teams.

Moreover, Dr. Joffe and his associates found no reduction in mortality at their hospital during other intervals in which three other studies found no such reductions.

In addition, "when we divided our data into equal 4- and 5-year periods, there was a highly significant reduction in hospital mortality in the ‘after’ periods compared with the ‘before’ periods at our hospital."

And the results were the same in a year-by-year logistic regression analysis of the data at their hospital.

"If we had implemented a [rapid response team], we would likely have misattributed the reduction in hospital mortality over time to this intervention," the researchers said.

"These results call into question the strength of the pediatric medical emergency team data from the cohort studies with historical controls," they noted (Arch. Ped. Adolesc. Med. 2011;165:419-23).

The studies that purport to show the benefits of rapid response teams also were flawed in other ways. For example, hospitals each used different criteria for calling the rapid response team, and the rates of making such calls varied markedly between hospitals, but such differences were not accounted for in analyses of the data.

No financial conflicts of interest were reported in Dr. Joffe’s report.

A children’s hospital with no rapid response team showed the same reductions in mortality during the same time frames as did hospitals that attributed their drops in mortality to their rapid response teams, according to a report in the May issue of the Archives of Pediatrics and Adolescent Medicine.

The "before-and-after" design of studies that purport to show the benefits of rapid response teams are inherently flawed. The fact that their own such before-and-after study reached the same conclusion at a hospital with no rapid response team shows that evidence supporting such teams is open to question, said Dr. Ari R. Joffe of the University of Alberta and Stollery Children’s Hospital, Edmonton, and his associates.

Pediatric rapid response teams, also known as medical emergency or critical care outreach teams, are groups of experts always ready to intervene when a cardiopulmonary arrest seems imminent and to respond to when one occurs. They have been touted as a means to reduce mortality from in-hospital cardiopulmonary arrest.

But the only studies that support this contention have relied on "before-and-after" designs in which present-day cohorts were compared with historical controls who were treated before the rapid response teams were implemented. This design fails to account for many variables known to affect mortality, such as temporal trends, differences in case mix, and differences in severity of illness.

To test the hypothesis that favorable study results actually were due to flaws in study design, Dr. Joffe and his colleagues reviewed mortality patterns at their own hospital, which has no rapid response team, during the same before-and-after periods.

They found a highly significant reduction in mortality at their hospital during the same intervals in which two studies found similar reductions and attributed them to their rapid response teams.

Moreover, Dr. Joffe and his associates found no reduction in mortality at their hospital during other intervals in which three other studies found no such reductions.

In addition, "when we divided our data into equal 4- and 5-year periods, there was a highly significant reduction in hospital mortality in the ‘after’ periods compared with the ‘before’ periods at our hospital."

And the results were the same in a year-by-year logistic regression analysis of the data at their hospital.

"If we had implemented a [rapid response team], we would likely have misattributed the reduction in hospital mortality over time to this intervention," the researchers said.

"These results call into question the strength of the pediatric medical emergency team data from the cohort studies with historical controls," they noted (Arch. Ped. Adolesc. Med. 2011;165:419-23).

The studies that purport to show the benefits of rapid response teams also were flawed in other ways. For example, hospitals each used different criteria for calling the rapid response team, and the rates of making such calls varied markedly between hospitals, but such differences were not accounted for in analyses of the data.

No financial conflicts of interest were reported in Dr. Joffe’s report.

A children’s hospital with no rapid response team showed the same reductions in mortality during the same time frames as did hospitals that attributed their drops in mortality to their rapid response teams, according to a report in the May issue of the Archives of Pediatrics and Adolescent Medicine.

The "before-and-after" design of studies that purport to show the benefits of rapid response teams are inherently flawed. The fact that their own such before-and-after study reached the same conclusion at a hospital with no rapid response team shows that evidence supporting such teams is open to question, said Dr. Ari R. Joffe of the University of Alberta and Stollery Children’s Hospital, Edmonton, and his associates.

Pediatric rapid response teams, also known as medical emergency or critical care outreach teams, are groups of experts always ready to intervene when a cardiopulmonary arrest seems imminent and to respond to when one occurs. They have been touted as a means to reduce mortality from in-hospital cardiopulmonary arrest.

But the only studies that support this contention have relied on "before-and-after" designs in which present-day cohorts were compared with historical controls who were treated before the rapid response teams were implemented. This design fails to account for many variables known to affect mortality, such as temporal trends, differences in case mix, and differences in severity of illness.

To test the hypothesis that favorable study results actually were due to flaws in study design, Dr. Joffe and his colleagues reviewed mortality patterns at their own hospital, which has no rapid response team, during the same before-and-after periods.

They found a highly significant reduction in mortality at their hospital during the same intervals in which two studies found similar reductions and attributed them to their rapid response teams.

Moreover, Dr. Joffe and his associates found no reduction in mortality at their hospital during other intervals in which three other studies found no such reductions.

In addition, "when we divided our data into equal 4- and 5-year periods, there was a highly significant reduction in hospital mortality in the ‘after’ periods compared with the ‘before’ periods at our hospital."

And the results were the same in a year-by-year logistic regression analysis of the data at their hospital.

"If we had implemented a [rapid response team], we would likely have misattributed the reduction in hospital mortality over time to this intervention," the researchers said.

"These results call into question the strength of the pediatric medical emergency team data from the cohort studies with historical controls," they noted (Arch. Ped. Adolesc. Med. 2011;165:419-23).

The studies that purport to show the benefits of rapid response teams also were flawed in other ways. For example, hospitals each used different criteria for calling the rapid response team, and the rates of making such calls varied markedly between hospitals, but such differences were not accounted for in analyses of the data.

No financial conflicts of interest were reported in Dr. Joffe’s report.

In patients with three-vessel or left main coronary artery disease, coronary artery bypass graft surgery provides greater relief from angina at 6 months and at 12 months after revascularization than does per?cutaneous coronary intervention with paclitaxel-eluting stents, according to a report in the New England Journal of Medicine.

EMBARGOED UNTIL 5 PM WED. 3/16

This benefit with CABG was consistent across a broad range of patient characteristics, said Dr. David J. Cohen of Saint Lukes Mid America Heart Institute, University of Missouri Kansas City, and his associates in the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial. SYNTAX was funded by Boston Scientific, maker of the paclitaxel-eluting stent.

SYNTAX was an international randomized trial in which 1,800 patients with three-vessel or left main coronary artery disease underwent either CABG or percutaneous coronary intervention (PCI) with placement of paclitaxel-eluting stents in 2005-2007.

The rate of the composite primary efficacy end point of death, myocardial infarction, stroke, or repeat revascularization was found to be lower with CABG at 1 year.

The current analysis was a quality-of-life substudy of SYNTAX aimed at determining whether the two approaches differed with regard to relief from angina and quality of life. It included 903 patients who had been randomly assigned to PCI with stents and 897 who had been assigned to CABG.

At baseline, approximately 12% of the subjects reported having daily angina and 20% reported no angina; the remaining subjects reported occasional angina.

Both PCI and CABG led to significant improvements in disease-specific and general health status over the course of 12 months, according to the investigators.

The primary quality-of-life end point was the score on the Seattle Angina Questionnaire angina frequency subscale. The improvement in this score was slightly but significantly greater with CABG than with PCI at 6 and 12 months.

?There were marked benefits with PCI as compared with CABG in general health-related quality of life as assessed by the SF-36 [Medical Outcomes Study 36-Item Short Form Health Survey] as well as EQ-SD [European Quality of Life

********* TEXT BREAK *********5-Dimensions instrument] at 1 month, but these differences had largely disappeared by 6 months, Dr. Cohen and his col?leagues reported (N. Engl. J. Med. 2011;364:1016-26).

<[stk 2]>Subgroup analysis showed that CABGs superiority in reducing the frequency of angina persisted across a broad range of patients. <[etk]>

<[stk 2]>Subjects who had reported daily or weekly angina at baseline showed significantly better relief after CABG than after PCI, although they reported that the extent of the benefit was small (76.3% vs. 71.6%, respectively, P = .05). <[etk]>

<[stk 3]>However, the majority of the study subjects had reported less frequent or no angina at baseline, and there was no significant difference in relief from angina between the two approaches in this large subgroup. <[etk]>

The researchers noted that these findings ?reflect only the first year of follow-up after revascularization; whether similar effects are observed over the long term is currently un?known.?

I have checked the following facts in my story:

MM     Drug names and dosages MSL

NA     Lab test values and their units NA

MM     Nos. are correct and add up, and percentages based on those nos. are correct MSL

MM    Citation MSL

MM     Investigators? names and affiliations MSL

MM     All other proper names (e.g., clinical trials; geographic, company, and test names) MSL

MM     Investigators? conflicts of interest and sponsor of study MSL

Best contact number = 301-325-5890; email = moon2dc@yahoo.com

Dr. Cohen and his associates reported that they had ties to numerous industry sources, including Boston Scientific. 

********* UNDERSET  1  LINES *********

In patients with three-vessel or left main coronary artery disease, coronary artery bypass graft surgery provides greater relief from angina at 6 months and at 12 months after revascularization than does per?cutaneous coronary intervention with paclitaxel-eluting stents, according to a report in the New England Journal of Medicine.

EMBARGOED UNTIL 5 PM WED. 3/16

This benefit with CABG was consistent across a broad range of patient characteristics, said Dr. David J. Cohen of Saint Lukes Mid America Heart Institute, University of Missouri Kansas City, and his associates in the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial. SYNTAX was funded by Boston Scientific, maker of the paclitaxel-eluting stent.

SYNTAX was an international randomized trial in which 1,800 patients with three-vessel or left main coronary artery disease underwent either CABG or percutaneous coronary intervention (PCI) with placement of paclitaxel-eluting stents in 2005-2007.

The rate of the composite primary efficacy end point of death, myocardial infarction, stroke, or repeat revascularization was found to be lower with CABG at 1 year.

The current analysis was a quality-of-life substudy of SYNTAX aimed at determining whether the two approaches differed with regard to relief from angina and quality of life. It included 903 patients who had been randomly assigned to PCI with stents and 897 who had been assigned to CABG.

At baseline, approximately 12% of the subjects reported having daily angina and 20% reported no angina; the remaining subjects reported occasional angina.

Both PCI and CABG led to significant improvements in disease-specific and general health status over the course of 12 months, according to the investigators.

The primary quality-of-life end point was the score on the Seattle Angina Questionnaire angina frequency subscale. The improvement in this score was slightly but significantly greater with CABG than with PCI at 6 and 12 months.

?There were marked benefits with PCI as compared with CABG in general health-related quality of life as assessed by the SF-36 [Medical Outcomes Study 36-Item Short Form Health Survey] as well as EQ-SD [European Quality of Life

********* TEXT BREAK *********5-Dimensions instrument] at 1 month, but these differences had largely disappeared by 6 months, Dr. Cohen and his col?leagues reported (N. Engl. J. Med. 2011;364:1016-26).

<[stk 2]>Subgroup analysis showed that CABGs superiority in reducing the frequency of angina persisted across a broad range of patients. <[etk]>

<[stk 2]>Subjects who had reported daily or weekly angina at baseline showed significantly better relief after CABG than after PCI, although they reported that the extent of the benefit was small (76.3% vs. 71.6%, respectively, P = .05). <[etk]>

<[stk 3]>However, the majority of the study subjects had reported less frequent or no angina at baseline, and there was no significant difference in relief from angina between the two approaches in this large subgroup. <[etk]>

The researchers noted that these findings ?reflect only the first year of follow-up after revascularization; whether similar effects are observed over the long term is currently un?known.?

I have checked the following facts in my story:

MM     Drug names and dosages MSL

NA     Lab test values and their units NA

MM     Nos. are correct and add up, and percentages based on those nos. are correct MSL

MM    Citation MSL

MM     Investigators? names and affiliations MSL

MM     All other proper names (e.g., clinical trials; geographic, company, and test names) MSL

MM     Investigators? conflicts of interest and sponsor of study MSL

Best contact number = 301-325-5890; email = moon2dc@yahoo.com

Dr. Cohen and his associates reported that they had ties to numerous industry sources, including Boston Scientific. 

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In patients with three-vessel or left main coronary artery disease, coronary artery bypass graft surgery provides greater relief from angina at 6 months and at 12 months after revascularization than does per?cutaneous coronary intervention with paclitaxel-eluting stents, according to a report in the New England Journal of Medicine.

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This benefit with CABG was consistent across a broad range of patient characteristics, said Dr. David J. Cohen of Saint Lukes Mid America Heart Institute, University of Missouri Kansas City, and his associates in the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial. SYNTAX was funded by Boston Scientific, maker of the paclitaxel-eluting stent.

SYNTAX was an international randomized trial in which 1,800 patients with three-vessel or left main coronary artery disease underwent either CABG or percutaneous coronary intervention (PCI) with placement of paclitaxel-eluting stents in 2005-2007.

The rate of the composite primary efficacy end point of death, myocardial infarction, stroke, or repeat revascularization was found to be lower with CABG at 1 year.

The current analysis was a quality-of-life substudy of SYNTAX aimed at determining whether the two approaches differed with regard to relief from angina and quality of life. It included 903 patients who had been randomly assigned to PCI with stents and 897 who had been assigned to CABG.

At baseline, approximately 12% of the subjects reported having daily angina and 20% reported no angina; the remaining subjects reported occasional angina.

Both PCI and CABG led to significant improvements in disease-specific and general health status over the course of 12 months, according to the investigators.

The primary quality-of-life end point was the score on the Seattle Angina Questionnaire angina frequency subscale. The improvement in this score was slightly but significantly greater with CABG than with PCI at 6 and 12 months.

?There were marked benefits with PCI as compared with CABG in general health-related quality of life as assessed by the SF-36 [Medical Outcomes Study 36-Item Short Form Health Survey] as well as EQ-SD [European Quality of Life

********* TEXT BREAK *********5-Dimensions instrument] at 1 month, but these differences had largely disappeared by 6 months, Dr. Cohen and his col?leagues reported (N. Engl. J. Med. 2011;364:1016-26).

<[stk 2]>Subgroup analysis showed that CABGs superiority in reducing the frequency of angina persisted across a broad range of patients. <[etk]>

<[stk 2]>Subjects who had reported daily or weekly angina at baseline showed significantly better relief after CABG than after PCI, although they reported that the extent of the benefit was small (76.3% vs. 71.6%, respectively, P = .05). <[etk]>

<[stk 3]>However, the majority of the study subjects had reported less frequent or no angina at baseline, and there was no significant difference in relief from angina between the two approaches in this large subgroup. <[etk]>

The researchers noted that these findings ?reflect only the first year of follow-up after revascularization; whether similar effects are observed over the long term is currently un?known.?

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Best contact number = 301-325-5890; email = moon2dc@yahoo.com

Dr. Cohen and his associates reported that they had ties to numerous industry sources, including Boston Scientific. 

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