Effect of gender on the outcomes of contemporary percutaneous coronary intervention.

Limited information exists regarding the outcomes of newer percutaneous coronary intervention (PCI) technologies in women. This study sought to determine whether female gender is an independent risk factor for PCI mortality and/or complications in contemporary practice. Using information from the National Cardiovascular Network (NCN) Database on 109,708 (33% women) PCI cases from 22 hospitals between January 1994 and January 1998, we examined the association of gender with unadjusted and risk-adjusted procedural outcomes. Women undergoing PCI were older, smaller, and had more comorbid illness than men, but less extensive coronary disease. Temporal trends in PCI device selection were similar in men and women. Compared with men, women had higher unadjusted procedural mortality rates (1.8% vs 1.0%, p <0.001), more strokes (0.4% vs 0.2%, p <0.001), and higher vascular complication rates (5.4% vs 2.7%, p <0.001). However, after adjusting for baseline clinical risk factors, and importantly, body surface area, women and men had similar PCI mortality risks (adjusted odds ratio 1.07, 95% confidence interval 0.92 to 1.24). Gender was not an independent risk factor for mortality among subgroups receiving coronary stent or atherectomy devices after risk adjustment. However, women undergoing PCI remained at higher risk for stroke, vascular complications, and repeat in-hospital revascularization than men, even after risk adjustment. We conclude that in contemporary practice, a patient's body size rather than gender, conveys independent risk for mortality after PCI.

Evolving trends in interventional device use and outcomes: results from the National Cardiovascular Network Database.

BACKGROUND: Although multiple new coronary interventional devices have been approved for marketing in the United States, use of these technologies in general clinical practice and their associated outcomes have not been reported. METHODS AND RESULTS: Using the National Cardiovascular Network's Coronary Interventional Database, we examined temporal trends in the use and outcomes of coronary stents, lasers, directional atherectomy, and rotational atherectomy devices at 12 US hospitals between January 1994 and December 1997 (n = 76,904). Over this period, the percentage of cases involving coronary stents rose more than 12-fold (from 5.4% in 1994 to 69.0% in 1997). In contrast, use of atherectomy-type devices declined significantly. Device selection was strongly influenced by the patient's coronary anatomy and procedural indication, but less by age, sex, or race. Device use also varied significantly among individual centers (4-fold variation among sites in stent use and 6-fold variation in atherectomy use) even after adjusting for patient characteristics. Although overall mortality rates were unchanged during this 4-year period, procedural success rates have improved and complication rates have declined significantly. Lengths of postprocedure hospital stay also fell significantly for all patients undergoing coronary intervention in this time period. CONCLUSIONS: Percutaneous interventional strategies are rapidly changing with the explosive growth of coronary stent use and the decline in use of atherectomy devices. Patient outcomes, including complication rates and postprocedure lengths of stay, have also improved as the new interventional strategies have been refined in clinical practice.

Effective pricing in the age of managed care.

Global, or package, pricing represents an attractive alternative to capitation, particularly among specialists. In this article, the author outlines why MCOs are increasingly seeking package pricing deals in today's health care market.