title: Mortality in Medicare patients undergoing elective percutaneous coronary intervention with or without antecedent stress testing.
abstract: BACKGROUND
  Guidelines advise testing for ischemia, such as with stress testing, before elective percutaneous coronary intervention (PCI). However, pre-PCI stress testing is not always done; the implications of this practice are not known. Our objective was to evaluate whether receipt of stress testing before elective PCI predicts mortality.
  
  
  RESULTS
  Using claims data from a 20% random sample of Medicare beneficiaries, we identified patients who had elective PCI in 2004 and followed them for a median of 3.4 years (n=23 887). Cox proportional hazards models were used to test the relationship of pre-PCI stress testing to survival. Population-based rates of elective PCI and stress testing were calculated for 306 hospital referral regions and categorized into 4 groups: high stress test/high PCI, low stress test/low PCI, low stress test/high PCI, and high stress/low PCI regions. Cox modeling was used to test whether category of hospital referral regions is related to survival. Patients who underwent pre-PCI stress testing had a 13% lower risk of mortality than those who did not (adjusted hazard ratio, 0.87; 95% confidence interval, 0.81-0.92) after median follow-up of 3.4 years. Patients in low stress test/high PCI regions had a 14% higher risk of mortality than those in high stress test/high PCI regions (adjusted hazard ratio, 1.14; 95% confidence interval, 1.03-1.26).
  
  
  CONCLUSIONS
  Pre-PCI stress testing is associated with lower mortality in patients undergoing elective PCI. Greater adherence to guidelines with respect to documenting ischemia before elective PCI may result in improved outcomes for patients.
authors.affiliation: Division of General Internal Medicine, University ofCalifornia-San Francisco, 3333 California St, San Francisco, CA 94118, USA. glin@medicine.ucsf.edu
authors.forename: Grace A
authors.initials: GA
authors.lastname: Lin
authors.forename: F Lee
authors.initials: FL
authors.lastname: Lucas
authors.forename: David J
authors.initials: DJ
authors.lastname: Malenka
authors.forename: Jonathan
authors.initials: J
authors.lastname: Skinner
authors.forename: Rita F
authors.initials: RF
authors.lastname: Redberg
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D005080:Exercise Test; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data*; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000401:mortality*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012017:Referral and Consultation / Q000706:statistics & numerical data; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
keywords: angioplasty; coronary disease; ischemia; revascularization