Focusing on hospital death rates may be costing patients their lives, new study suggests
Professor Gavin Murphy (left) and Dr Muhammad Rashid
Choosing the right heart treatment involves balancing short-term procedural safety with long-term survival, according to a new national study.
The study, published in the European Heart Journal Open by cardiac researchers from the University of Leicester, shows that there is a huge variation amongst regions of England for treating patients with severe coronary artery disease.
Importantly, areas where Percutaneous Coronary Intervention (PCI) is used more often than Coronary Artery Bypass Grafting (CABG) have the highest rates of death following treatment for coronary artery disease at five years.
CABG improves blood flow to the heart by surgically creating a bypass or detour around the blocked arteries, typically using a blood vessel from another part of the body. PCI is a non-surgical catheter-based procedure which uses a small balloon to inflate the narrowed artery (angioplasty) before placing a stent to improve blood flow to the heart. PCI is considered less invasive, but the long-term durability of surgery may offer a survival advantage for certain complex patients.
The retrospective study, which looked at 173,771 people undergoing PCI or CABG in England between 2009 and 2015 showed that regions with a preference for less invasive PCI, experienced fewer in-hospital deaths, but significantly more deaths overall within five years. The analysis suggests that for patients suitable for either treatment, prioritizing surgery could have potentially prevented nearly 3,000 deaths during the study period.
University experts say that the use of in-hospital mortality rates as a quality measure, could be driving the choice of treatment, rather than using long-term survival rates.
Professor Gavin Murphy, British Heart Foundation (BHF) Chair of Cardiac Surgery at the University of Leicester, and lead author of the study, said: “These results question the value of hospital mortality as an indicator of the quality of care for people requiring heart treatments.
“The Secretary of State for Health claimed in 2013 that the publication of hospital mortality rates following heart surgery would reduce deaths. Instead, this appears to have pushed people towards less invasive PCI treatments that have low in hospital mortality but do not have the same long-term benefits as surgery.”
Dr Muhammad Rashid, Senior Clinical Research Fellow from the Department of Cardiovascular Sciences at the University of Leicester, added: “While CABG carries higher upfront risk, our findings suggest it is associated with superior long-term survival in the context of multivessel disease treated in routine practice.
“This study highlights an urgent need for better evidence to inform clinical decisions, strategies to promote standardised evidence-based care pathways, and a shift towards quality metrics that prioritise long-term patient outcomes alongside the importance of periprocedural safety.”
Professor Enoch Akowuah, President-elect of the Society for Cardiothoracic Surgery in the UK and Ireland said: “This data shows evidence of significant regional variation and the negative impact of this variation on longer-term outcomes, including death rates. It is important that patients understand the trade-offs between earlier benefits of less invasive (PCI) procedures and possible longer-term risks, and that they have the correct information and support needed for shared decision-making.”