title: Comparative effectiveness of multivessel coronary bypass surgery and multivessel percutaneous coronary intervention: a cohort study.
abstract: BACKGROUND
  Randomized trials of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) suggest that patient characteristics modify the effect of treatment on mortality.
  
  
  OBJECTIVE
  To assess whether clinical characteristics modify the comparative effectiveness of CABG versus PCI in an unselected, general patient population.
  
  
  METHODS
  Observational treatment comparison using propensity score matching and Cox proportional hazards models.
  
  
  METHODS
  United States, 1992 to 2008.
  
  
  METHODS
  Medicare beneficiaries aged 66 years or older.
  
  
  METHODS
  Multivessel CABG or multivessel PCI.
  
  
  METHODS
  The CABG-PCI hazard ratio (HR) for all-cause mortality, with prespecified treatment-by-covariate interaction tests, and the absolute difference in life-years of survival in clinical subgroups after CABG or PCI, both over 5 years of follow-up.
  
  
  RESULTS
  Among 105 156 propensity score-matched patients, CABG was associated with lower mortality than PCI (HR, 0.92 [95% CI, 0.90 to 0.95]; P < 0.001). Association of CABG with lower mortality was significantly greater (interaction P ≤ 0.002 for each) among patients with diabetes (HR, 0.88), a history of tobacco use (HR, 0.82), heart failure (HR, 0.84), and peripheral arterial disease (HR, 0.85). The overall predicted difference in survival between CABG and PCI treatment over 5 years was 0.053 life-years (range, -0.017 to 0.579 life-years). Patients with diabetes, heart failure, peripheral arterial disease, or tobacco use had the largest predicted differences in survival after CABG, whereas those with none of these factors had slightly better survival after PCI.
  
  
  CONCLUSIONS
  Treatments were chosen by patients and physicians rather than being randomly assigned.
  
  
  CONCLUSIONS
  Multivessel CABG is associated with lower long-term mortality than multivessel PCI in the community setting. This association is substantially modified by patient characteristics, with improvement in survival concentrated among patients with diabetes, tobacco use, heart failure, or peripheral arterial disease.
  
  
  BACKGROUND
  National Heart, Lung, and Blood Institute.
authors.affiliation: Stanford University School of Medicine, Stanford, CA 94305, USA. hlatky@stanford.edu
authors.forename: Mark A
authors.initials: MA
authors.lastname: Hlatky
authors.forename: Derek B
authors.initials: DB
authors.lastname: Boothroyd
authors.forename: Laurence
authors.initials: L
authors.lastname: Baker
authors.forename: Dhruv S
authors.initials: DS
authors.lastname: Kazi
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Solomon
authors.forename: Tara I
authors.initials: TI
authors.lastname: Chang
authors.forename: David
authors.initials: D
authors.lastname: Shilane
authors.forename: Alan S
authors.initials: AS
authors.lastname: Go
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D015897:Comorbidity; D057186:Comparative Effectiveness Research; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000401:mortality / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D006278:Medicare; D062645:Percutaneous Coronary Intervention; D057216:Propensity Score; D016016:Proportional Hazards Models; D012307:Risk Factors; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology