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Office, clinic visits for angina declined since 1995
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Annual office and clinic visits for angina have decreased in the United States, from 3.6 million in 1995-1998 to 2.3 million visits in 2007-2010.
This decrease is consistent with trends showing reductions in angina-related hospitalizations and ED visits, according to researchers.
The study utilized physician office visit data from the National Ambulatory Medical Care Survey and outpatient hospital clinic visits data from the National Hospital Ambulatory Medical Care Survey from 1995 to 2010.
The researchers derived rates of angina visits using the ICD-9-CM codes. Unadjusted overall population rates and standardized rates were calculated for these visits, using a modified form of technical guidelines put forth by the Agency for Healthcare Research and Quality.
According to results, there was a significant decrease in angina visit rates per 100,000 (P<.05), with the sharpest decline evident from 1995-1998 to 2003-2007. Moreover, the diagnosis of coronary atherosclerotic disease decreased after 2002, whereas stress testing and referral to specialists, hospitals or other physicians doubled during some study intervals.
Changes to the ICD-9-CM coding guidelines for angina occurred during the study period, shifting angina from a primary to a secondary diagnosis, or eliminating angina from the coding entirely. The researchers theorized that this may have resulted in a drop-off in physician listing of angina as a diagnostic code. Additionally, the finding that nearly 50% of angina visits from 2007 to 2010 occurred in the southern United States could be attributable to a regional delay in adopting the coding changes, they said.
Despite the coding changes, it is likely that improvements in treatment and prevention of angina also played a role in its decreased presentation in office/clinic visits.
“Regardless of the reasons for the decline in angina outpatient visits, primary and secondary prevention strategies should continue to be a hallmark of care for patients with coronary artery disease,” the researchers wrote.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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E. Magnus Ohman, MD
This is an interesting study because it actually uses a survey to evaluate the outpatient setting in CVD. The authors have used a retrospective analysis of medical records using coding for angina as the method for detecting angina, and there appears to be a decline in coded angina for outpatient visits in patients in the United States.
I would question, though, if this is a real finding. In other words, is the incidence of angina truly decreasing, or is the decrease possibly [due to] the fact that ICD codes are being used to detect the incidence of angina? Most physicians are not really using coding to define symptoms, so using this method may not give a true picture of patients with angina.
I suspect that the angina rate is really not going down, but instead, what is going down is the typical angina rate — the type that is obvious to us all, and tells us that “This is true angina." Many more patients these days have atypical symptoms, such as shortness of breath or exertional fatigue, to name a few. These symptoms are typically not coded as angina, at least not in practice, because these are not, of course, what the physician, in the back of his or her mind, is thinking of as true angina.
So, while I think this is an interesting observation, I'm not entirely sure this is a true picture of how much the rate of angina has changed based on the research that they have performed. On the one side, maybe symptomatic angina is going down because we're doing a better job with medical therapy. That's a possibility, but I suspect that the decrease is more related to the fact that classical angina, as we have been taught about in medical school, is decreasing due to aging patient populations where atypical symptoms are more common.
I think the authors have done as good a job as you possibly can, bar actually having an independent person sitting in a clinic and going through the Rose questionnaire, to best define how you can ask the questions to more appropriately define angina. But the reality is that over the last 10 years we've learned a great deal about inpatient medicine by analyzing registries on how we perform and what we do in the hospital. In outpatient medicine, however, we are relatively data-poor, and have a lot more to learn about how to optimize our outpatient setting.
This paper suggests that we are getting better at managing angina. I would say, “maybe,” but I would like to see us get some more real-time data from the registries in this field so that we can better understand it.
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