CHANGES IN MORTALITY AFTER MYOCARDIAL REVASCULARIZATION IN THE ELDERLY - THE NATIONAL MEDICARE EXPERIENCE

Objective: To examine secular changes in the use and outcome of percutaneous transluminal coronary angioplasty and cardiac bypass graft surgery in the elderly. Design: A retrospective cohort study based on a longitudinal database created from the administrative files of Medicare. Setting: U.S. hospitals that perform myocardial revascularization procedures covered by Medicare. Patients: 225 915 consecutive patients who had angioplasty and 357 885 consecutive patients who had bypass surgery from 1987 to 1990. Measurements: The rates of angioplasty and bypass surgery use; unadjusted 30-day and I-year mortality rates after revascularization; and adjusted odds ratios for mortality by year of procedure for 1987 to 1990. Results: From 1987 to 1990, the rates of angioplasty and bypass surgery done in the elderly increased by 55% and 18%, respectively. During this period, 30-day unadjusted mortality rates after angioplasty and bypass surgery decreased by 25% (95% CI, 22% to 28%) and 12% (CI, 10% to 14%), and I-year mortality rates decreased by 10% (CI, 8% to 11%) and 8% (CI, 7% to 10%), respectively. After adjustment for changes in patient characteristics, 30-day mortality rates after these procedures decreased by 37% (CI, 32% to 41%) and 18% (CI, 14% to 21%), and I-year mortality rates decreased by 22% (CI, 18% to 25%) and 19% (CI, 16% to 21%), respectively. Conclusions: The use of cardiac revascularization procedures in the elderly has steadily increased. Patients who had revascularization are progressively older, have more coded comorbid conditions, and present with more acute diseases. Although elderly patients have apparently higher risk profiles, mortality rates after angioplasty and bypass surgery in the elderly have decreased, suggesting a national improvement in the outcomes of these interventions. Health policy decisions concerning revascularization procedures in the elderly must consider these trends in improved outcome.