Original Article

Geographic Variations in Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery Among Tennessee Elders

Authors: Barbara J. Kilbourne, PhD, Robert S. Levine, MD, Warren Lambert, PhD, Dustin Brown, MS, Gottlieb Friesinger, II, MD, Charles H. Hennekens, MD, ScD


Objectives: Coronary heart disease often presents with ST segment elevation acute myocardial infarction (STEMI). The American College of Cardiology/American Heart Association guidelines stress prompt reperfusion for STEMI. Examining geographic variations in treatment with PPCI (percutaneous primary coronary intervention) and CABG (coronary artery bypass graft) among metropolitan, micropolitan and non-micropolitan rural residents provides a descriptive basis for generating hypotheses concerning place and receipt of guidelines-based treatment.

Methods: Using ICD-9 codes for STEMI and excluding beneficiaries with pre-existing MI in claims data, yielded a subset of 18,775 Tennessee Medicare beneficiaries experiencing STEMI from 1996 to 2002. The outcome variable is type of treatment, i.e., in accord (PPCI or CABG present) or not in accord (PPCI or CABG absent) with guidelines. Independent variables include type county residence, hospital volume, race, gender, and age. Analyses include cross-tabulation and logistic regression, estimating separate models by age and type of MI.

Results: Micropolitan residents with STEMI have the lowest rates for PPCI (18.8%) versus 28.1% percent for metropolitan and 24.2% for non-micropolitan rural residents. CABG follows similar patterns at lower overall rates. Treatment at a heart center with high volume PPCI mediated the relationship between the likelihood of PPCI and place.

Conclusion: The correspondence between metropolitan and rural utilization suggests that access to a full range of treatment options and likelihood of "best practice" care is not dependent on metropolitan residence. This presents the possibility that with some policy changes, e.g., centralization of emergency heart care, the same may ultimately be true for micropolitan residents.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: executive summary: a report of the ACC/AHA Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines on the Management of Patients With Acute Myocardial Infarction). J Am Coll Cardiol 2004;44:671-719.
2. Kushner FG, Hand M, Smith SC Jr, et al. 2009 Focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Catheter Cardiovasc Intervent 2009;74:E25-E68.
3. Krumholz HM, Anderson JL, Brooks NH, et al. ACC/AHA Clinical Per formance Measures for Adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the ACC/AHA Task Force on Performance Measures (ST-Elevation and Non ST Elevation Myocardial Infarction Performance Writing Committee). J Am Coll Cardiol 2006;47:236-265.
4. Zahn R, Schiele R, Schneider S, et al. Primary angioplasty versus intravenous thrombolysis in acute myocardial infarction: can we define subgroups of patients benefiting most from primary angioplasty? Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction Registry and the Myocardial Infarction Registry. J Am Coll Cardiol 2001;37:1827-1835.
5. Andersen HR, Nielsen TT, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. NEJM 2003;349:733-742.
6. Fitzsimmons A, Lindbloom EJ. Patients with acute MI should be transferred for angioplasty. J Fam Pract 2003;52:940-941.
7. Goldenberg I, Matetzky S, Halkin A, et al. Primary Angioplasty with routine stenting compared with thrombolytic therapy in elderly patients with acute myocardial infarction. Am Heart J 2003;145:862-867.
8. Grines C, Patel A, Zijlstra F, et al. Primary coronary angioplasty compared with intravenous thrombolytic therapy for acute myocardial infarction: six-month follow up and analysis of individual patient data from randomized trials. Am Heart J 2003;145:47-57.
9. Jacobs AK. Primary angioplasty for acute myocardial infarction-is it worth the wait? NEJM 2003;349:798-800.
10. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of the literature. Lancet 2003;361:13-20.
11. Hartwell D, Colquitt J, Loveman E, et al. Clinical effectiveness and cost-effectiveness of immediate angioplasty for acute myocardial infarction: systematic review and economic evaluation. Health Technol Assess 2005;9:1-99.
12. Stukel TA, Lacus FL, Wennberg DE. Long-term outcomes of regional variations in intensity of invasive versus medical management of Medicare patients with acute myocardial infarction. JAMA 2005;293:1329-1337.
13. Terkelsen CJ, Christiansen EH, Sorenson JT, et al. Primary PPCI as the preferred reperfusion therapy in STEMI: it is a matter of time. Heart 2009;95:362-369.
14. Boden WE, Eagle K, Granger CB. Reperfusion strategies in acute ST-segment myocardial infarction: a comprehensive review of management strategies. J Am Coll Cardiol 2007;50:917-929.
15. Carver A, Rafelt S, Gershlick AH, et al. Longer-term follow-up of patients recruited to the ACT (Rescue Angioplasty Versus Conservative Treatment or Repeat Thrombolysis) trial. J Am Coll Cardiol 2009;54:127-129.
16. Aune E, Endresen K, Fox KA, et al. Effect of implementing routine early invasive strategy on one-year mortality in patients with acute myocardial infarction. J Am Coll Cardiol 2010;105:36-42.
17. Akdemir R, Karakurt O, Kilic H, et al. Effect of reperfusion therapy on index of myocardial performance in acute myocardial infarction: thrombolytics versus primary angioplasty. Heart Vessels 2010;25:87-91.
18. Nielsen PH, Maeng M, Busk M, et al. Primary angioplasty versus fibrinolysis in acute myocardial infarction: long term follow-up in the Danish acute myocardial infarction 2 trial. Circulation2010;121:1484-1491.
19. Kartha J, Topel EJ. Primary percutaneous coronary interventions vs. fibrinolytic therapy for acute ST-elevation myocardial infarction in the elderly. Am J Geriatr Cardiol 2006;15:19-21.
20. Ryan TJ, Anderson JL, Antman EM, et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guideline (Committee on management of Acute Myocardial Infarction). Circulation 1996;94:2341-2350.
21. Ryan TJ, Antman EM, Brooks NH, et al. 1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: executive summary and recommendations: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). Circulation 1999;100:1016-1030.
22. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). J AM Coll Cardiol 2004;44:E1-E211.
23. Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation 2008;117:296-329.
24. Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science 1973;182:1102-1108.
25. Sutherland JM, Fisher ES, Skinner JS. Getting past denial-the high cost of health care in the United States. NEJM 2009;36:1227-1230.
26. Zuckerman S, Waidmann T, Berenson R, et al. Clarifying sources of geographic differences in Medicare spending. N Engl J Med. 2010. DOI: 10.1056/NEJMsa0909253.
27. US Census Bureau. Metropolitan and micropolitan statistical areas. Available at:http://www.census.gov/population/www/metroareas/metroarea.html. Accessed June 30, 2010.
28. Plane DA, Henrie CJ, Perry MF. Migration up and down the urban hierarchy and across the life course. PNAS 2005;102:15313-15318.
29. Kiyota Y, Schneeweiss S, Glynn RJ, et al. Accuracy of Medicare claims-based diagnosis of acute myocardial infarction: estimating positive predictive value on the basis of review of hospital records. Am Heart J 2004;148:99-104.
30. Baldwin LM, MacLehose RF, Hart LG, et al. Quality of care for acute myocardial infarction in rural and urban U.S. hospitals. J Rural Health 2004;20:99-108.
31. Ellerbeck EF, Bhimaraj A, Perpich D. Organization of care for acute myocardial infarction in rural and urban hospitals in Kansas. J Rural Health 2004;20:99-108.
32. Ward MM, Jaana M, Wakefield DS, et al. What would be the effect of referral to high volume hospitals in a largely rural state? J Rural Health 2004;20:344-354.
33. Widemsky T, Budesinsky D, Vorac L, et al. Long distance transport for primary angioplasty vs. immediate thrombolysis in acute myocardial infarction (final results of the randomized national multicentre trial-PRAGUE-2). Eur Heart J 2003;24:94-104.
34. Pottenger BC, Dierks DB, Bhatt DL. Regionalization of care for ST-elevation myocardial infarction: is it too soon? Ann Emerg Med 2080;52:677-685.
35. Jacobs AK. Regionalized care for patients with ST-elevation myocardial infarction: it's closer than you think. Circulation 2006;113:1159-1161.
36. Saia F, Marrozzini C, Guastaroba P, et al. Lower long-term mortality within a regional system of care for ST-elevation myocardial infarction. Acute Card Care 1010;12:42-50.
37. Busk M, Maeng M, Rasmussen K, et al. The Danish multicentre randomized study of fibrinolytic therapy vs. primary angioplasty in acute myocardial infarction (the DANAMI-2 trial): outcome after 3 years follow up. Eur Heart J 2008;29:1259-1266.
38. Thune JJ, Hoefsten DE, Lindholm MG, et al. Simple risk stratification at admission to identify patients with reduced mortality from primary angioplasty. Circulation 2005;112:2017-2021.
39. Pedersen SH, Galatius S, Hansen PR, et al. Field triage reduces treatment delay and improves long-term clinical outcome in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. J Am Coll Cardiol 2009;54:2296-2302.
40. Kalla K, Christ G, Karnik R, et al. Implementation of guidelines improves standard of care: the Viennese registry on reperfusion strategies in ST-elevation myocardial infarction (Vienna STEMI registry). Circulation 2006;113:2398-2405.
41. Grosgurin O, Plojoux J, Keller PF, et al. Prehospital emergency physician activation of interventional cardiology team reduces door-to-balloon time in ST elevation myocardial infarctions. Swiss Med Wkly 2010;140:228-232.
42. Granger CB, Henry TD, Bates WER, et al. Development of systems of care for ST-elevation myocardial infarction patients. Circulation 2007;116:e55-e59.
43. Ting HH, Rihal CS, Gersh BJ, et al. Regional systems of care to optimize timeliness of reperfusion therapy for ST-elevation myocardial infarction: the Mayo Clinic STEMI Protocol. Circulation 2007;116:729-736.
44. Henry TD, Unger BT, Sharkey SW, et al. Design of a standardized system for transport of patients with ST-elevation myocardial infarction for percutaneous coronary intervention. Am Heart J2005;150:373-384.
45. Jollis JG, Roettig ML, Aluko AO, et al. Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction. JAMA 2007;298:2371-2380.
46. Holmes DR Jr, Bell MR, Gersh BJ, et al. Systems of care to improve timeliness of reperfusion therapy for ST-segment elevation myocardial infarction during off hours: the Mayo Clinic STEMI protocol.JACC Cardiovasc Intervent 2008;1:88-96.
47. Henry TD, Sharkey SW, Burke MN, et al. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation 2007;116:721-728.
48. Sivigangabalan G, Ong AT, Narayan A, et al. Effect of prehospital triage on revascularization times, left ventricular function, and survival in patients with ST-elevation myocardial infarction. Am J Cardiol2009;103:907-912.
49. Edwards JM, Carr BG. Improving patient outcomes from acute cardiovascular events through regionalized systems of care. Hosp Pract (Minn) 2010;38:54-62.
50. Clemmensen P, Loumann-Nielsen S, Sejersten M. Telemedicine fighting acute coronary syndrome. J Electrocardiol 2010;43:615-618.
51. Rezaee ME, Conley SM, Anderson TA, et al. Primary percutaneous coronary intervention for patients presenting with ST-elevation myocardial infarction: process improvements in rural prehospital care delivered by emergency medical services. Prog Cardiovasc Dis 2010;53:210-218.
52. Kosta K, Marcella SW, Shao YH, et al. Weekend versus weekday admission and mortality from myocardial infarction. NEJM 2007;356:1099-1109.
53. Gross BW, Dauterman KW, Moran MG, et al. An approach to shorten time to infarct patency in patients with ST-segment elevation myocardial infarction. Am J Cardiol 2007;99:1360-1363.
54. Rogers CC. The older population in 21st century rural America. USDA Web site. 2002. Available at:http://www.ers.usda.gov/publications/ruralamerica/ra173/ra173b.pdf. Accessed July 19, 2010.
55. Beal C. Rural America as a retirement destination. USDA Web site. 2005. Available at:http://www.ers.usda.gov/Amberwaves/June05/Findings/RetirementDestinations.htm. Accessed July 19, 2010.
56. Tai WT, Porell FW, Adams EK. Hospital choice of rural Medicare beneficiaries: patient attributes and the patient-physician relationship. Health Serv Res 2004;39:1903-1922.
57. Purdue University (Center for Regional Development) & Indiana University (Indiana Business Research Center). 2007. Unlocking rural competitiveness: the role of regional clusters. Indiana Business Research Center Web site. Available at: http://www.ibrc.indiana.edu/innovation/reports.html. Accessed October 10, 2007.
58. McClellan M, Noguchi H. Technological changes in heart-disease treatment. Does high tech mean low value? Am Econ Rev 1998;88:90-99.
59. Fang J, Negassa A, Gern RW, et al. Access to revascularization among patients with acute myocardial infarction in New York City-impact of hospital resources. J Urban Health 2006;83:1085-1094.
60. Kumbhani DJ, Cannon CP, Fonarow GC, et al. Association of hospital primary angioplasty volume in ST-segment elevation myocardial infarctions with quality and outcomes. JAMA 2009;302:2207-2213.
61. Magid DJ, Calonge BN, Rumsfeld JS, et al. Relation between hospital primary angioplasty volume and mortality for patients with acute MI treated with primary angioplasty vs. thrombolytic therapy. JAMA 2000;284:3131-3138.
62. McGrath PD, Wennberg DE, Dickens JD, et al. Relation between operator and hospital volume following percutaneous coronary interventions in the era of the coronary stent. JAMA 2000;284:3139-3140.
63. Al-Dehneh A, Parikh R, Hamden A, et al. Ethnic minorities exhibit reduction in door-to balloon time comparable to whites with newly implemented physician activation protocol (Code STEMI). J Invasive Cardiol 2009;21:506-510.
64. Alter DA, Naylor CD, Austin P, et al. Long-term MI outcomes at hospitals with or without on-site revascularization. JAMA 2001;285:2102-2108.
65. Wennberg DE, Lucas FL, Siewers AE, et al. Outcomes of percutaneous coronary interventions performed at centers without and with onsite coronary artery bypass graft surgery. JAMA 2004;292:1961-1968.
66. Wharton TP, McNamara NS. Management of acute coronary syndromes in the community hospital without cardiac surgical capability: how can access to interventional therapy be improved? Am J Cardiovasc Drugs 2001;1:375-385.
67. Waters RE 2nd, Singh KP, Roe MT, et al. Rationale and strategies for implementing community-based transfer protocols for primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction. J Am Coll Cardiol 2004;43:2153-2159.
68. Aplin R, Tiede D, Lovitz C, et al. A regional system for delivery of primary percutaneous coronary intervention in ST-elevation myocardial infarctions: STEMI-St Cloud. J Invasive Cardiol 2009;21:639-644.
69. Fang J, Alderman MH. Does supplemental private insurance affect care of Medicare recipients hospitalized for myocardial infarction? Am J Public Health 2004;94:778-782.