Journal of Public Health Advance Access published online on February 29, 2008
Journal of Public Health, doi:10.1093/pubmed/fdn016
Hospital and operator variations in drug-eluting stent use: a multi-level analysis of 5967 consecutive patients in Scotland
David Austin, Clinical Research Fellow in Cardiology1,
Keith G. Oldroyd, Consultant Cardiologist and Honorary Senior Lecturer2
Alex McConnachie, Statistician3
Rachel Slack, Scottish Cardiac Registers Co-ordinator1
Hany Eteiba, Consultant Cardiologist and Honorary Senior Lecturer4
Andrew D. Flapan, Consultant Cardiologist5
Kevin P. Jennings, Consultant Cardiologist6
Robin J. Northcote, Consultant Cardiologist7
Alistair C. H. Pell, Consultant Cardiologist8
Ian R. Starkey, Consultant Cardiologist9
Jill P. Pell, Professor of Public Health1
1 Section of Public Health and Health Policy, University of Glasgow, 1 Lilybank Gardens, G12 8RZ Glasgow, UK
2 Western Infirmary, Glasgow, UK
3 Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
4 Glasgow Royal Infirmary, Glasgow, UK
5 Edinburgh Royal Infirmary, Edinburgh, UK
6 Aberdeen Royal Infirmary, Aberdeen, UK
7 Victoria Infirmary, Glasgow, UK
8 Monklands Hospital, Airdrie, Lanarkshire, UK
9 Western General Hospital, Edinburgh, UK
Address correspondence to Jill P. Pell, E-mail: j.pell{at}clinmed.gla.ac.uk
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Abstract |
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Objective To determine whether drug-eluting stent (DES) use varies among Scottish hospitals, and the extent to which any variations are explained by differences between operators, patients and lesions.
Methods Multi-level analysis of consecutive patients treated with percutaneous coronary intervention (PCI) between April 2005 and March 2006 in Scotland, using the Scottish Coronary Revascularization Registry.
Results A total of 38 operators performed 5967 PCI procedures on 8489 lesions. Crude level of DES use was 47.6%, and the results varied among hospitals (range 30.6–61.8%, 
2 = 341.6, P < 0.0001). There was significant between-operator variation in the null model. This was attenuated by the addition of hospital as a fixed effect. Nonetheless, the final model demonstrated significant between-operator variability [
2 = 0.486 (0.249–0.971)] and between-hospital variation, after case-mix adjustment.
Conclusions Within Scotland, marked variation existed among hospitals in the use of DES. Operator was the most important factor at patient level, and hospital of treatment, rather than case-mix, was the most important modifier of between-operator variation. Patient selection for DES is complex and may contribute to much of the variations demonstrated. Consensus criteria would provide more detail than is included in current guidance, may aid decision-making for individual patients, reduce opportunity costs and ensure equity of access.
Keywords: coronary artery disease, drug-eluting stents, multi-level model, percutaneous coronary intervention, practice variation