Instrumental variable analysis to compare effectiveness of stents in the extremely elderly.
Instrumental variable analysis to compare effectiveness of stents in the extremely elderly.
复制标题
工具变量分析比较老年人支架的有效性。
DOI：
10.1161/circoutcomes.113.000476
复制
发表时间：
2014
期刊：
影响因子：
--
通讯作者：
Mauri,Laura
中科院分区：
文献类型：
--
作者：
Yeh,RobertW;Vasaiwala,Samip;Forman,DanielE;Silbaugh,TreacyS;Zelevinski,Katya;Lovett,Ann;Normand,Sharon-LiseT;Mauri,Laura
背景评价新的治疗方法是极具挑战性的极端老年人。工具变量的方法确定变量与治疗分配进行调整比较，可以克服更传统的approaches.Methods和ResultsAmong年龄≥85岁的所有患者接受经皮冠状动脉介入治疗在非联邦医院在马萨诸塞州2003年和2009年（n=2690）之间，我们确定了季度药物洗脱支架（DES）的使用率作为一个工具变量。我们使用2阶段最小二乘工具变量分析方法估计DES与裸金属支架结局的风险调整差异。每季度DES使用率为15%至88%。DES组未校正的1年死亡率为14.5%，裸金属支架组为23.0%（风险差异为-8.5%，P<0.001），与随机试验结果相比，这是一个令人难以置信的结果。使用工具变量分析，DES与1年死亡率无差异（风险差异，-0.8%;P=0.76）或出血（风险差异，2.3%;P=0.33），靶血管血运重建显著减少（风险差，-8.3%; P<0.0001）。结论采用工具变量分析，DES与裸金属支架相比，死亡率和出血率相似，靶血管血运重建率显著降低。非常老。使用率的变化可能是一个有用的工具变量，以促进在随机试验中代表性不足的群体的比较有效性。
BackgroundEvaluating novel therapies is challenging in the extremely elderly. Instrumental variable methods identify variables associated with treatment allocation to perform adjusted comparisons that may overcome limitations of more traditional approaches.Methods and ResultsAmong all patients aged ≥85 years undergoing percutaneous coronary intervention in nonfederal hospitals in Massachusetts between 2003 and 2009 (n=2690), we identified quarterly drug-eluting stent (DES) use rates as an instrumental variable. We estimated risk-adjusted differences in outcomes for DES versus bare metal stents using a 2-stage least squares instrumental variable analysis method. Quarterly DES use ranged from 15% to 88%. Unadjusted 1-year mortality rates were 14.5% for DES versus 23.0% for bare metal stents (risk difference, −8.5%;P<0.001), an implausible finding compared with randomized trial results. Using instrumental variable analysis, DES were associated with no difference in 1-year mortality (risk difference, −0.8%;P=0.76) or bleeding (risk difference, 2.3%;P=0.33) and with significant reduction in target vessel revascularization (risk difference, −8.3%;P<0.0001).ConclusionsUsing an instrumental variable analysis, DES were associated with similar mortality and bleeding and a significant reduction in target vessel revascularization compared with bare metal stents in the extremely elderly. Variation in use rates may be useful as an instrumental variable to facilitate comparative effectiveness in groups underrepresented in randomized trials.