Influence of the Bypass Angioplasty Revascularization Investigation National Heart, Lung, and Blood Institute Diabetic Clinical Alert on practice patterns: Results from the National Cardiovascular Network database

Background - In 1995, the Bypass Angioplasty Revascularization Investigation (BARI) found that patients with diabetes had a survival benefit when treated with surgical revascularization versus balloon angioplasty, prompting a National Heart Lung and Blood Institute (NHLBI) "Clinical Alert". The influence of the BARI findings and of the Clinical Alert on practice patterns is unknown. Methods and Results - The practice patterns of coronary revascularization among patients with diabetes and multivessel coronary artery disease (CAD) were analyzed using data collected in 1994 to 1997 from 13 centers participating in the National Cardiovascular Network. The study population included patients with diabetis and multivessel CAD who underwent elective coronary revascularization (n=9619). Over the 4 years of the study, the Clinical Alert had no significant impact on the proportion of diabetic patients undergoing percutaneous revascularization (28.6% before versus 26.8% after the Clinical Alert; P=0.06). Among individual hospitals, the probability of diabetic patients receiving percutaneous revascularization varied by >13-fold (4.3% to 56.6%). Adjusting for clinical factors and the BARI Clinical Alert did not alter this variability. Among the investigators surveyed, although 91% were aware of the Clinical Alert and 76% felt the findings were valid, >50% felt the Clinical Alert had limited or no impact on their personal or institution's care patterns. Conclusions - Limited consensus exists regarding the most appropriate method of revascularization for diabetic patients with multivessel CAD. The results from a large, randomized, clinical trial and subsequent Clinical Alert had no measurable impact on this practice variability.