• Chart of the day: What happened to CABG and angioplasty?

    One of these things is not like the others:

    That’s a figure from Amitabh Chandra, Jonathan Holmes, and Jonathan Skinner (PDF). The authors explain:

    In the case of cardiac stenting and bypass surgery, there was a dramatic run-up in their use during the 1990s for heart attacks and other heart disease, and with a particularly rapid rise in the use of stents (wire cylindrical devices used to maintain blood flow in the heart’s arteries). During the mid-2000s, however, several randomized trials suggested very modest benefits arising from the use of stents for the most common types of heart disease, leading to a downturn in the use of these procedures.

    According to this story, it’s all an angioplasty effect. Hold the CABG. However, no doubt the rise of statins also played a large role, probably affecting both CABG and angioplasty.

    UPDATE: NodakEM on Twitter points out that smoking cessation also likely played a role in reducing incidence of heart disease.

    UPDATE 2: By email, Amitabh Chandra points to this paper.


    • “(1) trials suggested very modest benefits arising from the use of stents for the most common types of heart disease,(2) leading to a downturn in the use of these procedures.”

      I don’t know that 2 should follow 1. It might be true that there was a downturn in the use of these procedures and some of that downturn was due to 1, but the statement draws a direct cause and effect relationship which I believe is not warranted. I don’t wish to criticize because that relationship might have been clarified in the rest of the paper. Statins and smoking cessation have been listed as other causes, but one should also take into account that initially there was a “backlog” of cases that needed treatment which would cause the rapid rise each time the procedure was made easier and safer. That “backlog” is finished so it seems logical that the number of cases performed today should be expected to be much lower.

      • Emily, you claim a “backlog” as fact. Do you have evidence of this “backlog?” How big was it? How many cases did it include? How long would it take, given supply of surgeons, case demand, ability to pay, etc. to work through it? This is an evidence-based blog. Let’s see some.

        • Sheldon, I wasn’t as much drawing a conclusion as adding a an additional variable to a prior conclusion (take note of the other additions made, statins and smoking cessation). Also take note that I placed the word backlog in quotes for lack of a better term though I think the term is accurate.

          My response was empirical. If there was a long term need, but no solution then with time more and more people would develop the need. When a solution suddenly exists all those people in need will be in line for the solution. When the price falls or the safety, in this case, improves one will again see a larger number of people looking for a solution they couldn’t or wouldn’t have had earlier.

          If you are looking for evidence then look at the numbers when different procedures were introduced, when the procedures were approved by insurance, when safety issues were addressed. One cannot do a double blinded study to prove what you are asking, but then one can’t do a double blinded study to prove that jumping out of a plane without a parachute leads to worse results than with a parachute.

    • As a Primary Physician who finished formal training in 1973, the combined use of an aspirin, beta-blocker, ace-inhibitor/arb and statin for stabilizing coronary artery disease has been one of the most spectacular therapeutic advances within our nation’s healthcare. I literally can not remember any patient in our practice who died from an acute MI in the last ten years. Co-incidentally, my ability to fine-tune a tretment plan for congestive heart failure has also been substantially enhanced, even for someone in their 90s with COPD. It will be interesting to look at this chart after the doubling of the Medicare-eligible pospulation
      between 2010 and 2030. I am planning on reading this Blog when I turn 90!