Variation in the use of percutaneous coronary interventions among older patients with acute coronary syndromes: a multilevel study in Fukuoka, Japan

Abstract

Background Variation in health care delivery among regions and hospitals has been observed worldwide and reported to have resulted in health inequalities. Regional variation of percutaneous coronary intervention (PCI) was previously reported in Japan. This study aimed to assess the small-area and hospital-level variations and to examine the influence of patient and hospital characteristics on the use of PCI. Methods Data provided by the Fukuoka Prefecture Latter-stage Elderly Insurance Association was used. There were 11,821 patients aged ≥65 years with acute coronary syndromes who were identified from 2015 to 2017. Three-level multilevel logistic regression analyses were performed to quantify the small-area and hospital variations, as well as, to identify the determinants of PCI use. Results The results showed significant variation (δ2 = 0.744) and increased PCI use (MOR = 2.425) at the hospital level. After controlling patient- and hospital-level characteristics, a large proportional change in cluster variance was found at the hospital level (PCV 14.7%). Fixed-effect estimation results showed that females, patients aged ≥80 years old, hypertension and dyslipidemia had significant association with the use of PCI. Hospitals with high physician density had a significantly positive relationship with PCI use. Conclusions Patients receiving care in hospitals located in small areas have equitable access to PCI. Hospital-level variation might be originated from the oversupply of physicians. A balanced number of physicians and beds should be taken into consideration during healthcare allocation. A treatment process guideline on PCI targeting older patients is also needed to ensure a more equitable access for healthcare resources.

Population-Based Multilevel Models to Estimate the Management Strategies for Acute Myocardial Infarction in Older Adults with Dementia

“…However, the invasive procedure rate for AMI among patients with dementia was remarkably lower compared with previous research on PCI use. [40][41][42] The reasons for this low rate may include complex comorbidities, uncertain benefits and insufficient guidelines, resulting in patients' conservative preferences for treatment and physicians' difficulty in making judgements and recommendations for these patients. Our findings showed that patients undergoing invasive procedures usually had fewer comorbidities but were prescribed more drugs, compared with patients who did not undergo these procedures.…”