Changes in Geographic Variation in the Use of Percutaneous Coronary Intervention for Stable Ischemic Heart Disease After Publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial

Study Questions:

What was the impact of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial on geographic variation in the use of percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD)?


The authors assessed changes in utilization and geographic variation in PCI in 67 hospital referral regions using the State Inpatient Database. Data from seven states (Arizona, California, Florida, Massachusetts, Maryland, New Jersey, and New York) were used to calculate age- and sex-adjusted rates of PCI for stable CAD before (2006) and after (2008) publication of the COURAGE trial, and these were compared with contemporaneous changes in PCI volume for acute coronary syndrome.


The study population was comprised of a total of 272,659 PCIs for stable CAD performed at 526 hospitals. PCI volume for stable CAD declined by 25% (p < 0.001) and decreased by 12% for acute coronary syndrome (p < 0.001) following publication of the COURAGE trial. Most of the decline occurred in the hospital referral regions, with the highest levels of utilization pre-COURAGE trial (35% decline in the highest tertile vs. 18% in the lowest). Variation in PCI for stable CAD declined by 28% (0.53 vs. 0.40) after publication of the COURAGE trial, but geographic variation remained higher for stable disease compared with that for acute coronary syndrome (0.40 vs. 0.17).


The authors concluded that there was a significant decline in use of and geographic variation in PCI for stable disease following the publication of the COURAGE trial.


Geographic variation in PCI has received considerable attention both in the medical and in the lay press in recent months. Part of this variation relates to differences in risk factor profile of the population, but a large proportion of the variation probably relates to differences in practice patterns. The current study demonstrates that areas with high utilization were more likely to see a decline in PCI rates following publication of the COURAGE trial. This suggests that practice patterns in these areas may respond to emerging data, and future studies should focus on defining strategies to modify practice patterns in a fashion that enhances optimal utilization of PCI across the country.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Interventions and ACS, Interventions and Coronary Artery Disease

Keywords: Coronary Artery Disease, Acute Coronary Syndrome, Myocardial Ischemia, New Jersey, Coronary Disease, New York, Angioplasty, Balloon, Coronary, Massachusetts, Percutaneous Coronary Intervention, Maryland, Rumen, California, Florida, Cardiology, Hydrogen-Ion Concentration, Drug Evaluation

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