title: Major geographical variations in elective coronary revascularization by stents or surgery in England.
abstract: OBJECTIVE
  Revascularization in stable coronary artery disease (CAD) can be achieved through percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) depending on the anatomical pattern of CAD, comorbidities and patient preference. Recent studies in the USA, Canada and Australia show marked local variation in the PCI/CABG ratio that is unexplained by patient-related factors. This current study assesses the geographical variation in elective coronary revascularization interventions across England and discusses its appropriateness.
  
  
  METHODS
  The rates and actual procedure numbers of total CABG, total PCIs and elective PCIs were collated for each of 151 primary care trusts (PCTs). The 'elective PCI/total CABG ratio' was taken as an indicator of elective coronary revascularization practices. The Index of Multiple Deprivation (IMD) for PCTs was taken as a marker of deprivation.
  
  
  RESULTS
  In 2010/2011, the degree of variation in elective PCI/total CABG ratios across 151 PCTs in England was >13-fold (min = 0.36, max = 4.74, median = 1.19, interquartile range = 0.98, 1.73). The ratio was not correlated to the IMD 2010 rank of the PCTs (Spearman's ρ = 0.08, P = 0.36) and was not explained by the volume of interventions performed.
  
  
  CONCLUSIONS
  Despite clear evidence-based guidelines for intervention, marked geographical variation in elective coronary revascularization practices also exists in England. This variation is unexplained by procedure volume or deprivation, suggesting the contribution of unwarranted influences which may include practitioner preference. To reduce this level of unwarranted variation, we suggest that all interventions should be underpinned by internationally recognized guidelines or approved by a multidisciplinary team approach (The Heart Team).
authors.affiliation: Green Templeton College, University of Oxford, Oxford sheharyarbaig@mail.com.
authors.forename: Sheharyar S
authors.initials: SS
authors.lastname: Baig
authors.affiliation: Centre for Statistics in Medicine, University of Oxford, Oxford, UK.
authors.forename: Douglas G
authors.initials: DG
authors.lastname: Altman
authors.affiliation: Department of Cardiovascular Surgery, John Radcliffe Hospital, Headington, Oxford, UK.
authors.forename: David P
authors.initials: DP
authors.lastname: Taggart
mesh_terms: D003324:Coronary Artery Disease / Q000601:surgery*; D017558:Elective Surgical Procedures / Q000379:methods* / Q000706:statistics & numerical data*; D004739:England; D006801:Humans; D009204:Myocardial Revascularization / Q000706:statistics & numerical data*; D016896:Treatment Outcome
keywords: Coronary artery bypass graft; Geographical variation; Percutaneous coronary intervention; Stent; Unwarranted variation