Medical Practice Variations in Elective Surgery

  • Enrique Bernal-Delgado
  • Manuel Ridao-López
  • Sandra Garcia-Armesto
Reference work entry
Part of the Health Services Research book series (HEALTHSR)


The study of variations in elective surgery may be considered a paradigm within the field of medical practice variations. It was the focus of the first seminal work on unwarranted variations where the initial insights and first major hypotheses regarding medical practice variations were based on patterns of variations seen in rates of elective procedures. The taxonomy regarding the underlying causes of variations was largely built upon elective surgery. The current debate on policy implications is populated with numerous examples of elective procedures.

Stemming from work by Glover, Wennberg, Gittelsohn, and McPherson and based on a comprehensive literature review, this chapter is aimed at characterizing variations in elective surgery. The chapter presents the current evidence on variations, describing and interpreting the factors affecting variations in the rates of elective procedures and highlighting lessons expected to have immediate implications for health policy.


Percutaneous Coronary Intervention Coronary Artery Bypass Graft Elective Surgery Knee Replacement National Surgical Quality Improvement Program 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



  1. Bernal-Delgado E. How can we improve effectiveness (quality) by reducing the gap between research and action? Gac Sanit. 2008;22 Suppl 1:19–26.PubMedCrossRefGoogle Scholar
  2. Bernal-Delgado E, García-Armesto S, Peiró S, Atlas VPM Group. Atlas of variations in medical practice in Spain: the Spanish National Health Service under scrutiny. Health Policy. 2014;114(1):15–30.PubMedCrossRefGoogle Scholar
  3. Bohmer G, Pain P, Watt C, et al. Maximising health gain within available resources in the New Zealand public health system. Health Policy. 2001;55:37–50.PubMedCrossRefGoogle Scholar
  4. Elshaug AG, Hiller JE, Tunis SR, Moss JR. Challenges in Australia policy processes for disinvestment from existing, ineffective health care practices. Australia and New Zealand. Health Policy. 2007;4:23.Google Scholar
  5. Elshaug AG, Watt AM, Moss JR, et al. Policy perspectives on the obsolescence of health technologies in Canada. In: Discussion paper Canadian Agency for Drugs and Technologies in Health for the Health Technology Strategy Policy Forum. CADTH. 2009. Accessed 18 Apr 2013.
  6. Espallargues M. Necesidades y priorización. Jornada sobre artroplastias: perspectivas clínicas, de gestión y de investigación en servicios sanitarios. Ministerio de Sanidad y Consumo y Red IRYSS. Madrid, 2 de junio 2005.Google Scholar
  7. García-Armesto S, Campillo-Artero C, Bernal-Delgado E. Disinvestment in the age of cost-cutting sound and fury. Tools for the Spanish National Health System. Health Policy. 2013;32:180–85. doi:10.1016/j.healthpol.2013.01.007. Accessed 18 Apr 2013.Google Scholar
  8. Glover JA. The incidence of tonsillectomy in school children. Proc R Soc Med. 1938;31(1219):95–112.Google Scholar
  9. Ibáñez-Beroiz B, Librero-López J, Peiró-Moreno S, et al. Shared component modelling as an alternative to assess geographical variations in medical practice: gender inequalities in hospital admissions for chronic diseases. BMC Med Res Methodol. 2011;11:172.PubMedPubMedCentralCrossRefGoogle Scholar
  10. Ibargoyen-Roteta N, Gutiérrez-Ibarluzea I, Asua J. Guiding the process of health technology disinvestment. Health Policy. 2010;98:218–26.PubMedCrossRefGoogle Scholar
  11. Khuri SF, Daley J, Henderson W, Hur K, Demakis J, Aust JB, et al. The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg. 1998;228(4):491–507.PubMedPubMedCentralCrossRefGoogle Scholar
  12. McPherson K, Wennberg JE, Hovind OB, et al. Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Engl J Med. 1982;307:1310–4.PubMedCrossRefGoogle Scholar
  13. McPherson K, Gon G, Scott M. International variations in a selected number of surgical procedures. OECD health working papers. 2013. doi:10.1787/5k49h4p5g9mw-en. Accessed 18 Apr 2013.Google Scholar
  14. NICE. Prostate cancer: diagnosis and treatment. 2008. Accessed 18 Apr 2013.
  15. NICE. Prosthetic intervertebral disc replacement in the lumbar spine. 2009. Accessed 18 Apr 2013.
  16. Nuti S, Vainieri M, Bonini A. Disinvestment for re-allocation: a process to identify priorities in healthcare. Health Policy. 2010;95:137–43.PubMedCrossRefGoogle Scholar
  17. OECD. Health at a glance 2011: OECD indicators. OECD Publishing. 2011. doi:10.1787/health_glance-2011-en. Accessed 18 Apr 2013.Google Scholar
  18. Ridao-López M, García-Armesto S, Peiró S, et al. Evaluación de la variabilidad geográfica de la práctica médica como herramienta de evaluación de políticas sanitarias. Presupuesto y Gasto Público. 2012;68:193–210.Google Scholar
  19. Salive ME, Mayfield JA, Weissman NW. Patient Outcomes Research Teams and the Agency for Health Care Policy and Research. Health Serv Res. 1990;25(5):697–708.PubMedPubMedCentralGoogle Scholar
  20. Varnauskas E. Twelve-year follow-up of survival in the randomized European Coronary Surgery Study. N Engl J Med. 1988;319(6):332–7.PubMedCrossRefGoogle Scholar
  21. Veroff D, Marr A, Wennberg D. Enhanced support for shared decision making reduced costs of care for patients with preference-sensitive conditions. Health Aff. 2013;32:285–93.CrossRefGoogle Scholar
  22. Wennberg JE. Small area analysis and the medical care outcome problem. In: Sechest L, Perren E, Bunker J, editors. AHCPR conference proceedings: research methodology strengthening causal interpretations of non-experimental data. Rockville: DHSS Publications; 1990. p. 90–3454.Google Scholar
  23. Wennberg JE, Gittelsohn A. Health care delivery in Maine (I): patterns of use of common surgical procedures. J Maine Med Assoc. 1975;66:123–30.PubMedGoogle Scholar
  24. Wennberg JE, Barnes BA, Zubkoff M. Professional uncertainty and the problem of supplier-induced demand. Soc Sci Med. 1982;16(7):811–24.PubMedCrossRefGoogle Scholar
  25. Wennberg JE, Cooper MM, et al. The quality of medical care in the United States: the Dartmouth Atlas of Health Care 1999. Chicago: American Hospital Publishing; 1999. p. 224–7.Google Scholar


  1. Erickson BK, Larson DR, St Sauver JL, et al. Changes in incidence and indications of tonsillectomy and adenotonsillectomy, 1970–2005. Otolaryngol Head Neck Surg. 2009;140:894–901.PubMedCrossRefGoogle Scholar
  2. Fedeli U, Marchesan M, Avossa F, et al. Variability of adenoidectomy/tonsillectomy rates among children of the Veneto Region, Italy. BMC Health Serv Res. 2009;9:25.PubMedPubMedCentralCrossRefGoogle Scholar
  3. Jacobs K, Jorissen M, Lemkens P. Current Belgian adenotonsillectomy practice: a survey among Belgian ENT specialists. B-ENT. 2010;6:83–90.PubMedGoogle Scholar
  4. Lock C, Wilson J, Steen N, et al. Childhood tonsillectomy: who is referred and what treatment choices are made? Baseline findings from the North of England and Scotland Study of Tonsillectomy and Adenotonsillectomy in Children (NESSTAC). Arch Dis Child. 2010;95:203–8.PubMedCrossRefGoogle Scholar
  5. Materia E, Di Domenicantonio R, Baglio G, et al. Epidemiology of tonsillectomy and/or adenoidectomy in Italy. Pediatr Med Chir. 2004;26:179–86.PubMedGoogle Scholar
  6. van den Akker EH, Schilder AG, Kemps YJ, et al. Current indications for (adeno)tonsillectomy in children: a survey in The Netherlands. Int J Pediatr Otorhinolaryngol. 2003;67:603–7.PubMedCrossRefGoogle Scholar
  7. van Staaij BK, van den Akker EH, Rovers MM, et al. Effectiveness of adenotonsillectomy in children with mild symptoms of throat infections or adenotonsillar hypertrophy: open, randomised controlled trial. BMJ. 2004;329:651.PubMedPubMedCentralCrossRefGoogle Scholar

Cesarean Section

  1. Baicker K, Buckles KS, Chandra A. Geographic variation in the appropriate use of cesarean delivery. Health Aff. 2006;25:355–67.CrossRefGoogle Scholar
  2. Carayol M, Blondel B, Zeitlin J, et al. Changes in the rates of caesarean delivery before labour for breech presentation at term in France: 1972–2003. Eur J Obstet Gynecol Reprod Biol. 2007;132:20–6.PubMedCrossRefGoogle Scholar
  3. Chen CS, Lin HC, Liu TC, et al. Urbanization and the likelihood of a cesarean section. Eur J Obstet Gynecol Reprod Biol. 2008;141:104–10.PubMedCrossRefGoogle Scholar
  4. Clark SL, Belfort MA, Hankins GD, et al. Variation in the rates of operative delivery in the United States. Am J Obstet Gynecol. 2007;196:526. e1–e5.PubMedCrossRefGoogle Scholar
  5. Fairley L, Dundas R, Leyland AH. The influence of both individual and area based socioeconomic status on temporal trends in Caesarean sections in Scotland 1980–2000. BMC Public Health. 2011;11:330.PubMedPubMedCentralCrossRefGoogle Scholar
  6. Freitas PF, Drachler Mde L, Leite JC, et al. Inequalities in cesarean delivery rates by ethnicity and hospital accessibility in Brazil. Int J Gynaecol Obstet. 2009;107:198–201.PubMedCrossRefGoogle Scholar
  7. Grytten J, Monkerud L, Sørensen R. Adoption of diagnostic technology and variation in caesarean section rates: a test of the practice style hypothesis in Norway. Health Serv Res. 2012;47:2169–89.PubMedPubMedCentralCrossRefGoogle Scholar
  8. Hanley GE, Janssen PA, Greyson D. Regional variation in the cesarean delivery and assisted vaginal delivery rates. Obstet Gynecol. 2010;115:1201–8.PubMedCrossRefGoogle Scholar
  9. Márquez-Calderón S, Ruiz-Ramos M, Juárez S, et al. Caesarean delivery in Andalusia, Spain: relationship with social, clinical and health services factors (2007–2009). Rev Esp Salud Publica. 2011;85:205–15.PubMedCrossRefGoogle Scholar


  1. Abenhaim HA, Azziz R, Hu J, et al. Socioeconomic and racial predictors of undergoing laparoscopic hysterectomy for selected benign diseases: analysis of 341487 hysterectomies. J Minim Invasive Gynecol. 2008;15:11–5.PubMedCrossRefGoogle Scholar
  2. Beckmann K, Iosifidis P, Shorne L, et al. Effects of variations in hysterectomy status on population coverage by cervical screening. Aust N Z J Public Health. 2003;27:507–12.PubMedCrossRefGoogle Scholar
  3. Bottle A, Aylin P. Variations in vaginal and abdominal hysterectomy by region and trust in England. BJOG. 2005;112:326–8.PubMedCrossRefGoogle Scholar
  4. Domenighetti G, Luraschi P, Casabianca A, et al. Effect of information campaign by the mass media on hysterectomy rates. Lancet. 1988;2:1470–3.PubMedCrossRefGoogle Scholar
  5. Hanstede MM, Burger MJ, Timmermans A, et al. Regional and temporal variation in hysterectomy rates and surgical routes for benign diseases in the Netherlands. Acta Obstet Gynecol Scand. 2012;91:220–5.PubMedCrossRefGoogle Scholar
  6. Jacoby VL, Vittinghoff E, Nakagawa S, et al. Factors associated with undergoing bilateral salpingo-oophorectomy at the time of hysterectomy for benign conditions. Obstet Gynecol. 2009;113:1259–67.PubMedPubMedCentralCrossRefGoogle Scholar
  7. Nielsen SL, Daugbjerg SB, Gimbel H, et al. Steering Committee of Danish Hysterectomy Database. Use of vaginal hysterectomy in Denmark: rates, indications and patient characteristics. Acta Obstet Gynecol Scand. 2011;90:978–84.PubMedCrossRefGoogle Scholar
  8. Peiró S, Meneu R, Bernal-Delgado E. Effectiveness, variation and inequalities. Hysterectomies and prostatectomies due to neoplasm in Spain (2002–2004). Rev Esp Salud Publica. 2009;83:109–21.PubMedCrossRefGoogle Scholar
  9. Ribeiro SC, Ribeiro RM, Santos NC, et al. A randomized study of total abdominal, vaginal and laparoscopic hysterectomy. Int J Gynaecol Obstet. 2003;83:37–43.PubMedCrossRefGoogle Scholar
  10. Twijnstra AR, Blikkendaal MD, van Zwet EW, et al. Predictors of successful surgical outcome in laparoscopic hysterectomy. Obstet Gynecol. 2012;119:700–8.PubMedCrossRefGoogle Scholar


  1. Bañez LL, Terris MK, Aronson WJ, et al. Race and time from diagnosis to radical prostatectomy: does equal access mean equal timely access to the operating room? Results from the SEARCH database. Cancer Epidemiol Biomarkers Prev. 2009;18:1208–12.PubMedPubMedCentralCrossRefGoogle Scholar
  2. Hayen A, Smith DP, Patel MI, et al. Patterns of surgical care for prostate cancer in NSW, 1993–2002: rural/urban and socio-economic variation. Aust N Z J Public Health. 2008;32:417–20.PubMedCrossRefGoogle Scholar
  3. Hayn MH, Orom H, Shavers VL, et al. Racial/ethnic differences in receipt of pelvic lymph node dissection among men with localized/regional prostate cancer. Cancer. 2011;117:4651–8.PubMedPubMedCentralCrossRefGoogle Scholar
  4. Nambudiri VE, Landrum MB, Lamont EB, et al. Understanding variation in primary prostate cancer treatment within the Veterans Health Administration. Urology. 2012;79:537–45.PubMedCrossRefGoogle Scholar
  5. Oliver SE, Donovan JL, Peters TJ, et al. Recent trends in the use of radical prostatectomy in England: the epidemiology of diffusion. BJU Int. 2003;91:331–6.PubMedCrossRefGoogle Scholar
  6. Trinh QD, Schmitges J, Sun M, et al. Improvement of racial disparities with respect to the utilization of minimally invasive radical prostatectomy in the United States. Cancer. 2012;118:1894–900.PubMedCrossRefGoogle Scholar
  7. Wilt TJ, Shamliyan TA, Taylor BC, et al. Association between hospital and surgeon radical prostatectomy volume and patient outcomes: a systematic review. J Urol. 2008;180:820–8.PubMedCrossRefGoogle Scholar

Knee and Hip Replacement

  1. Ackerman IN, Dieppe PA, March LM, et al. Variation in age and physical status prior to total knee and hip replacement surgery: a comparison of centers in Australia and Europe. Arthritis Rheum. 2009;61:166–73.PubMedCrossRefGoogle Scholar
  2. Bang H, Chiu YL, Memtsoudis SG, et al. Total hip and total knee arthroplasties: trends and disparities revisited. Am J Orthop. 2010;39:E95–102.PubMedGoogle Scholar
  3. Centers for Disease Control and Prevention (CDC). Racial disparities in total knee replacement among Medicare enrollees – United States, 2000–2006. MMWR Morb Mortal Wkly Rep. 2009;58:133–8.Google Scholar
  4. Cobos R, Latorre A, Aizpuru F, et al. Variability of indication criteria in knee and hip replacement: an observational study. BMC Musculoskelet Disord. 2010;11:249.PubMedPubMedCentralCrossRefGoogle Scholar
  5. Dixon T, Shaw ME, Dieppe PA. Analysis of regional variation in hip and knee joint replacement rates in England using Hospital Episodes Statistics. Public Health. 2006;120:83–90.PubMedCrossRefGoogle Scholar
  6. Dunlop DD, Manheim LM, Song J, et al. Age and racial/ethnic disparities in arthritis-related hip and knee surgeries. Med Care. 2008;46:200–8.PubMedCrossRefGoogle Scholar
  7. Francis ML, Scaife SL, Zahnd WE, et al. Joint replacement surgeries among medicare beneficiaries in rural compared with urban areas. Arthritis Rheum. 2009;60:3554–62.PubMedCrossRefGoogle Scholar
  8. Hanchate AD, Zhang Y, Felson DT, et al. Exploring the determinants of racial and ethnic disparities in total knee arthroplasty: health insurance, income, and assets. Med Care. 2008;46:481–8.PubMedPubMedCentralCrossRefGoogle Scholar
  9. Hawkins K, Escoto KH, Ozminkowski RJ, et al. Disparities in major joint replacement surgery among adults with Medicare supplement insurance. Popul Health Manag. 2011;14:231–8.PubMedCrossRefGoogle Scholar
  10. Iorio R, Robb WJ, Healy WL, et al. Orthopaedic surgeon workforce and volume assessment for total hip and knee replacement in the United States: preparing for an epidemic. J Bone Joint Surg Am. 2008;90:1598–605.PubMedCrossRefGoogle Scholar
  11. Irgit K, Nelson CL. Defining racial and ethnic disparities in THA and TKA. Clin Orthop Relat Res. 2011;469:1817–23.PubMedPubMedCentralCrossRefGoogle Scholar
  12. Judge A, Welton NJ, Sandhu J, et al. Geographical variation in the provision of elective primary hip and knee replacement: the role of socio-demographic, hospital and distance variables. J Public Health. 2009;31:413–22.CrossRefGoogle Scholar
  13. Kurtz SM, Ong KL, Schmier J, et al. Primary and revision arthroplasty surgery caseloads in the United States from 1990 to 2004. J Arthroplasty. 2009;24:195–203.PubMedCrossRefGoogle Scholar
  14. Laudicella M, Siciliani L, Cookson R. Waiting times and socioeconomic status: evidence from England. Soc Sci Med. 2012;74:1331–41.PubMedCrossRefGoogle Scholar
  15. Mäkelä KT, Peltola M, Häkkinen U, et al. Geographical variation in incidence of primary total hip arthroplasty: a population-based analysis of 34,642 replacements. Arch Orthop Trauma Surg. 2010;130:633–9.PubMedCrossRefGoogle Scholar
  16. Ong K, Lau E, Manley M, et al. Patient, hospital, and procedure characteristics influencing total hip and knee arthroplasty procedure duration. J Arthroplasty. 2009;24:925–31.PubMedCrossRefGoogle Scholar
  17. Quintana JM, Escobar A, Arostegui I, et al. Health-related quality of life and appropriateness of knee or hip Joint replacement. Arch Intern Med. 2006;166:220–6.PubMedCrossRefGoogle Scholar
  18. Rahman MM, Kopec JA, Sayre EC, et al. Effect of sociodemographic factors on surgical consultations and hip or knee replacements among patients with osteoarthritis in British Columbia. Canada J Rheumatol. 2011;38:503–9.PubMedCrossRefGoogle Scholar
  19. Skinner J, Weinstein JN, Sporer SM, et al. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med. 2003;349:1350–9.PubMedCrossRefGoogle Scholar
  20. Suarez-Almazor ME, Souchek J, Kelly PA, et al. Ethnic variation in knee replacement: patient preferences or uninformed disparity? Arch Intern Med. 2005;165:1117–24.PubMedCrossRefGoogle Scholar
  21. Tomek IM, Sabel AL, Froimson MI, et al. A collaborative of leading health systems finds wide variations in total knee replacement delivery and takes steps to improve value. Health Aff. 2012;31:1329–38.CrossRefGoogle Scholar

Cardiac Revascularization

  1. Aguado-Romeo MJ, Márquez-Calderón S, Buzón-Barrera ML, et al. Hospital mortality in acute coronary syndrome: differences related to gender and use of percutaneous coronary procedures. BMC Health Serv Res. 2007;7:110.PubMedPubMedCentralCrossRefGoogle Scholar
  2. Alter DA, Tu JV, Austin PC, Naylor CD. Waiting times, revascularization modality, and outcomes after acute myocardial infarction at hospitals with and without on-site revascularization facilities in Canada. J Am Coll Cardiol. 2003;42(3):410–9.PubMedCrossRefGoogle Scholar
  3. Aragam KG, Moscucci M, Smith DE, et al. Trends and disparities in referral to cardiac rehabilitation after percutaneous coronary intervention. Am Heart J. 2011;161:544–51.PubMedCrossRefGoogle Scholar
  4. Austin D, Oldroyd KG, McConnachie A, et al. Hospital and operator variations in drug-eluting stent use: a multi-level analysis of 5967 consecutive patients in Scotland. J Public Health. 2008;30:186–93.CrossRefGoogle Scholar
  5. Bao Y, Kamble S. Geographical distribution of surgical capabilities and disparities in the use of high-volume providers: the case of coronary artery bypass graft. Med Care. 2009;47:794–802.PubMedCrossRefGoogle Scholar
  6. Brown CP, Ross L, Lopez I, et al. Disparities in the receipt of cardiac revascularization procedures between blacks and whites: an analysis of secular trends. Ethn Dis. 2008;18(2 Suppl 2). S2-112-7.Google Scholar
  7. Caillier JG. Race, gender, and cardiovascular disease: do disparities exist at hospitals that serve majority black populations when patients present with ischemic heart disease and myocardial infarction? J Cult Divers. 2006;13:202–7.PubMedGoogle Scholar
  8. Coumbe A, John R, Kuskowski M, et al. Variation of mortality after coronary artery bypass surgery in relation to hour, day and month of the procedure. BMC Cardiovasc Disord. 2011;11:63.PubMedPubMedCentralCrossRefGoogle Scholar
  9. Cram P, Bayman L, Popescu I, et al. Racial disparities in revascularization rates among patients with similar insurance coverage. J Natl Med Assoc. 2009;101:1132–9.PubMedCrossRefGoogle Scholar
  10. Gabriel Steg P, Iung B, Feldman LJ, et al. Determinants of use and outcomes of invasive coronary procedures in acute coronary syndromes: results from ENACT. Eur Heart J. 2003;24:613–22.PubMedCrossRefGoogle Scholar
  11. Gaglia Jr MA, Steinberg DH, Pinto Slottow TL, et al. Racial disparities in outcomes following percutaneous coronary intervention with drug-eluting stents. Am J Cardiol. 2009;103:653–8.PubMedCrossRefGoogle Scholar
  12. Gaglia Jr MA, Torguson R, Xue Z, et al. Insurance type influences the use of drug-eluting stents. JACC Cardiovasc Interv. 2010;3:773–9.PubMedCrossRefGoogle Scholar
  13. Grilli R, Guastaroba P, Taroni F. Effect of hospital ownership status and payment structure on the adoption and use of drug-eluting stents for percutaneous coronary interventions. CMAJ. 2007;176:185–90.PubMedPubMedCentralCrossRefGoogle Scholar
  14. Hannan EL, Wu C, Chassin MR. Differences in per capita rates of revascularization and in choice of revascularization procedure for eleven states. BMC Health Serv Res. 2006;6:35.PubMedPubMedCentralCrossRefGoogle Scholar
  15. Hannan EL, Racz M, Walford G, et al. Differences in utilization of drug-eluting stents by race and payer. Am J Cardiol. 2007;100:1192–8.PubMedCrossRefGoogle Scholar
  16. Kamble S, Boyd AS. Health disparities and social determinants of health among African-American women undergoing percutaneous coronary interventions (PCI). J Cult Divers. 2008;15:132–42.PubMedGoogle Scholar
  17. Kilbourne BJ, Levine RS, Lambert W, et al. Geographic variations in percutaneous coronary interventions and coronary artery bypass graft surgery among Tennessee elders. South Med J. 2011;104:389–96.PubMedCrossRefGoogle Scholar
  18. Kim DH, Daskalakis C, Lee AN, et al. Racial disparity in the relationship between hospital volume and mortality among patients undergoing coronary artery bypass grafting. Ann Surg. 2008;248:886–92.PubMedCrossRefGoogle Scholar
  19. Korda RJ, Clements MS, Dixon J. Socioeconomic inequalities in the diffusion of health technology: uptake of coronary procedures as an example. Soc Sci Med. 2011;72:224–9.PubMedCrossRefGoogle Scholar
  20. Likosky DS, Goldberg JB, DiScipio AW, et al. Variability in surgeons’ perioperative practices may influence the incidence of low-output failure after coronary artery bypass grafting surgery. Circ Cardiovasc Qual Outcomes. 2012;5:638–44.PubMedCrossRefGoogle Scholar
  21. Lin GA, Dudley RA, Redberg RF. Why physicians favor use of percutaneous coronary intervention to medical therapy: a focus group study. J Gen Intern Med. 2008;23:1458–63.PubMedPubMedCentralCrossRefGoogle Scholar
  22. Meyers BM, Vira T, Chow C, et al. Coronary artery bypass graft surgery and primary percutaneous coronary intervention choices in patients with similar coronary anatomy: a computer-based simulation examines the sex gap. Can J Cardiol. 2009;25:649–53.PubMedPubMedCentralCrossRefGoogle Scholar
  23. Movahed MR, Ramaraj R, Jamal MM, et al. Nationwide trends in the utilisation of percutaneous coronary intervention (PCI) in the United States of America based on gender and ethnicities. EuroIntervention. 2009;5:343–8.PubMedCrossRefGoogle Scholar
  24. Mukamel D, Glance L, Weimer D, et al. Racial variations in the choice of on-pump versus off-pump coronary artery bypass grafting. J Health Serv Res Policy. 2007;12:31–5.PubMedPubMedCentralCrossRefGoogle Scholar
  25. Mukherjee D, Wainess RM, Dimick JB, et al. Variation in outcomes after percutaneous coronary intervention in the United States and predictors of periprocedural mortality. Cardiology. 2005;103:143–7.PubMedCrossRefGoogle Scholar
  26. Napan S, Kashinath R, Orig M, et al. Racial difference in cardiovascular outcomes following percutaneous coronary intervention in a public health service patient population. J Invasive Cardiol. 2010;22:168–73.PubMedGoogle Scholar
  27. Noguchi H, Shimizutani S, Masuda Y. Regional variations in medical expenditure and hospitalization days for heart attack patients in Japan: evidence from the Tokai Acute Myocardial Study (TAMIS). Int J Health Care Finance Econ. 2008;8:123–44.PubMedCrossRefGoogle Scholar
  28. Quin JA, Sheng S, O’Brien SM, et al. Regional variation in patient risk factors and mortality after coronary artery bypass grafting. Ann Thorac Surg. 2011;92:1277–82.PubMedCrossRefGoogle Scholar
  29. Riley RF, Don CW, Powell W, et al. Trends in coronary revascularization in the United States from 2001 to 2009: recent declines in percutaneous coronary intervention volumes. Circ Cardiovasc Qual Outcomes. 2011;4:193–7.PubMedPubMedCentralCrossRefGoogle Scholar
  30. Saleh SS, Hannan EL, Ting L. A multistate comparison of patient characteristics, outcomes, and treatment practices in acute myocardial infarction. Am J Cardiol. 2005;96:1190–6.PubMedCrossRefGoogle Scholar
  31. Thompson CA, Kaplan AV, Friedman BJ, et al. Gender-based differences of percutaneous coronary intervention in the drug-eluting stent era. Catheter Cardiovasc Interv. 2006;67:25–31.PubMedCrossRefGoogle Scholar
  32. Tu JV, Ko DT, Guo H, et al. Determinants of variations in coronary revascularization practices. CMAJ. 2012;184:179–86.PubMedPubMedCentralCrossRefGoogle Scholar
  33. West RM, Cattle BA, Bouyssie M, et al. Impact of hospital proportion and volume on primary percutaneous coronary intervention performance in England and Wales. Eur Heart J. 2011;32:706–11.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Enrique Bernal-Delgado
    • 1
  • Manuel Ridao-López
    • 1
  • Sandra Garcia-Armesto
    • 2
  1. 1.Unit for Research in Health Services and PoliciesInstitute for Health Sciences in Aragon (IACS), ISS-AragonZaragozaSpain
  2. 2.ARAI+D FoundationZaragozaSpain

Personalised recommendations