Cardiac Surgery

Center for the Evaluative Clinical Sciences

Dartmouth atlas of health Care: stuDies of surgiCal Variation CarDiaC surgery report �

Cardiac Surgery Since the publication of the first edition of the Dartmouth Atlas of Health Care in 1996, information about population-based, age-, sex-, and race-adjusted rates of particular surgical procedures among U.S. hospital referral regions (HRRs) has been available to the public. Hospital referral regions represent regional health care markets for tertiary medical care. Each HRR contains at least one hospital that performs major cardiovascular procedures and neurosurgery. More information on how hospital referral regions were defined is available in the Methods section of this document, and in the Appendix on the Geography of Health Care, located on our web site.



Table of Contents

Coronary Revascularization: Coronary Artery Bypass Grafting and Percutaneous Coronary Interventions ___ 3

National Trends in Utilization and Spending _______________________________________________________ 3

Regional Variations in Rates of Coronary Artery Bypass Grafting _______________________________________ 9

Regional Variations in Rates of Percutaneous Coronary Interventions _________________________________ 11

Coronary Artery Bypass Grafting Surgery in Redding, California ______________________________________ 13

Percutaneous Coronary Interventions in Elyria, Ohio _______________________________________________ 15

Aortic and Mitral Valve Replacement ______________________________________________________________ 17

National Trends in Utilization __________________________________________________________________ 17

Regional Variations in Rates of Aortic and Mitral Valve Replacement __________________________________ 18

Aortic and Mitral Valve Replacement in Redding, California __________________________________________ 20

Methods ______________________________________________________________________________________ 22

Appendix Table Title ____________________________________________________________________________ 23



2.0

4.0

6.0

8.0

10.0

12.0

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

PCI

CABG

Coronary Revascularization: Coronary Artery Bypass Grafting and Percutaneous Coronary Interventions

National Trends in Utilization and Spending

Rates of coronary artery bypass grafting (CABG) surgery for the treatment of coronary artery disease rose and then fell during the decade 1992-2003. In 1992, the U.S. aver-age rate of CABG was 5.3 per 1,000 Medicare enrollees. The rate peaked at 6.4 per 1,000 enrollees in 1997, and then decreased to 5.2 per 1,000 in 2003. By contrast, rates of percutaneous coronary interventions (PCI) rose steadi-ly. In 1992, the U.S. average rate of PCI was 4.9 per 1,000 Medicare enrollees. The rate increased over the following decade, to 7.5 per 1,000 enrollees in 1997, reaching 11.3 per 1,000 in 2003.

U.S

. ave

rag

e d

isch

arg

e ra

te p

er

1,00

0 M

edic

are

enro

llees

Figure 1. Trends in Rates of CABG and PCI, 1992-2003



$0.0

$1.0

$2.0

$3.0

$4.0

$5.0

$6.0

$7.0

$8.0

$9.0

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

PCI

CABG

Medicare spending for inpatient stays for coronary revascularization showed a similar pattern (Figure 2). Infla-tion-adjusted spending for CABG rose and then fell during the decade; by 2003 the rate had decreased by 2.4%, from $4.43 billion in 1992 to $4.32 billion in 2003. Spending for PCI, by contrast, increased more than 150% during the same period, from $1.55 billion to $4.03 billion. In 1992, PCI represented 26% of total spending for coronary revas-cularization procedures; by 2003, PCI accounted for 48.2% of spending for coronary revascularization.

Figure 2. Inpatient Medicare Reimbursements (in billions of dollars) for Coronary Revascularization Procedures, 1992-2003

Tota

l rei

mb

urs

emen

ts (b

illio

ns)

(a

dju

sted

for i

nfla

tio

n)



R2 = 0.140.0

5.0

10.0

15.0

20.0

25.0

30.0

0.0 2.0 4.0 6.0 8.0 10.0 12.0

R2 = 0.04

-100.0

0.0

100.0

200.0

300.0

400.0

500.0

600.0

700.0

-50.0 0.0 50.0 100.0 150.0

PCI is often considered a substitute for more invasive bypass surgery; however, rates of the two procedures were in fact positively correlated among hospital refer-ral regions in 2003 (R2 = .14) (Figure 3). There was also a positive correlation between the changes in CABG and PCI rates from 1992 to 2003 (Figure 4). While in some regions a decline in CABG was associated with an increase in PCI, the overall relationship was positive (R2 = .04). Rates of CABG increased in about half of the 306 HRRs in the U.S., while rates of PCI rose in almost every region, declining slightly in only two.

Figure 3. The Relationship Between Rates of CABG and PCI, 2003

Figure 4. The Relationship Between Changes in Rates of CABG and PCI, 1992-2003

CABG discharges per 1,000 Medicare enrollees (2003)

PCI d

isch

arg

es p

er 1

,000

M

edic

are

enro

llees

(200

3)

Change in CABG rates, 1992-2003 (%)

Ch

ang

e in

PC

I rat

es, 1

992-

2003

(%)



0.0

2.0

4.0

6.0

8.0

10.0

0.0 2.0 4.0 6.0 8.0 10.0

R2 = 0.29

0.0

10.0

20.0

30.0

40.0

50.0

0.0 10.0 20.0 30.0 40.0 50.0

R2 = 0.18

Though PCI increased much more sharply than CABG, rates of both procedures in 1992 were predictive of rates in 2003 (Figures 5 and 6). 29% of the variation in CABG rates among HRRs in 2003 was predicted by the variation in 1992, while 18% of the variation in PCI rates in 2003 was associated with the variation in 1992.

Figure 5. The Relationship Between Rates of CABG in 1992 and 2003

Figure 6. The Relationship Between Rates of PCI in 1992 and 2003

CABG discharges per 1,000 Medicare enrollees (1992)

CA

BG

dis

char

ges

per

1,0

00

Med

icar

e en

rolle

es (2

003)

PCI discharges per 1,000 Medicare enrollees (1992)

PCI d

isch

arg

es p

er 1

,000

M

edic

are

enro

llees

(200

3)In Figures 5 and 6, the 45 degree line

represents equality between rates; if the dot representing an HRR is

located above the line, enrollees in that HRR experienced higher rates of

utilization in 2003 than in 1992.



R2 = 0.070.0

2.0

4.0

6.0

8.0

10.0

12.0

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

R2 = 0.010.0

5.0

10.0

15.0

20.0

25.0

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0

Rates of CABG were weakly correlated with the per-cap-ita supply of cardiovascular surgeons in hospital referral regions in 1999 (the latest year for which workforce data are available). Regions with more than 2.5 cardiovascular surgeons per 100,000 residents did not have higher rates of CABG than areas with fewer than 1.5 surgeons per 100,000 (Figure 7). PCI rates were not correlated with the per-capita supply of cardiologists in 1999 (Figure 8).

Figure 7. The Relationship Between Cardiovascular Surgeons per 100,000 Residents and Rates of CABG, 1999

Figure 8. The Relationship Between Cardiologists per 100,000 Residents and Rates of PCI, 1999

Cardiovascular Surgeons per 100,000 residents (1999)

CA

BG

dis

char

ges

per

1,0

00

Med

icar

e en

rolle

es (1

999)

Cardiologists per 100,000 residents (1999)

PC

I dis

char

ges

per

1,0

00

Med

icar

e en

rolle

es (1

999)



R2 = 0.780.0

10.0

20.0

30.0

40.0

50.0

0.0 10.0 20.0 30.0 40.0 50.0

However, rates of coronary angiography, the primary diag-nostic test for determining the severity of coronary artery disease, were strongly correlated with rates of coronary revascularization in 2003 (R2 = .78), indicating that the more physicians looked for surgically treatable coronary artery disease, the more invasive treatment was provided (Figure 9).

Figure 9. The Relationship Between Rates of Coronary Angiography and Coronary Revascularization, 2003

Coronary angiography per 1,000 Medicare enrollees (2003)C

oro

nar

y re

vasc

ula

riza

tio

n p

er

1,00

0 M

edic

are

enro

llees

(200

3)



1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

Regional Variations in Rates of Coronary Artery Bypass Grafting

There was substantial regional variation in rates of CABG among Medicare enrollees in 2003 (Figure 10). Rates var-ied by a factor of five, from 1.9 per 1,000 enrollees to 9.5. Among the hospital referral regions where rates of CABG were highest were Mobile, Alabama (9.5); McAllen, Texas (9.1); Alexandria, Louisiana (8.4); Lincoln, Nebraska (8.2); and Flint, Michigan (8.2). Regions with rates lower than the national average of 5.2 CABG procedures per 1,000 enroll-ees included Grand Junction, Colorado (1.9); Honolulu (2.3); San Francisco (3.0); Boise, Idaho (3.1); and St. Cloud, Minnesota (3.1).

Figure 10. Rates of CABG Among Hospital Referral Regions, 2003

Each point represents the rate in one of the 306 HRRs in the United States.

CA

BG

dis

char

ges

per

1,0

00

Med

icar

e en

rolle

es (2

003)


Dartmouth atlas of health Care: stuDies of surgiCal Variation CarDiaC surgery report �0

1.30 to 1.83 (41)1.10 to < 1.30 (65)0.90 to < 1.10 (104)0.75 to < 0.90 (57)0.37 to < 0.75 (39)Not Populated

Ratio of Rates of CABG Surgeryto the U.S. Averageby Hospital Referral Region (2003)

Map 1. Coronary Artery Bypass Grafting

In 41 hospital referral regions, rates of CABG were at least 30% higher than the United States average of 5.2 per 1,000 Medicare enrollees. In 39 hospital referral regions, rates were more than 25% lower than the national average.


Dartmouth atlas of health Care: stuDies of surgiCal Variation CarDiaC surgery report ��

3.0

8.0

13.0

18.0

23.0

28.0

33.0

38.0

43.0

Regional Variations in Rates of Percutaneous Coronary Interventions

Rates of percutaneous coronary interventions varied more than tenfold among Medicare enrollees in 2003 (Figure 11). Among the hospital referral regions where rates of PCI were highest were Elyria, Ohio (42.0); Lafayette, Loui-siana (27.5); St. Joseph, Michigan (23.4); Grand Forks, North Dakota (23.0); and Rome, Georgia (21.0). Regions with rates lower than the national average of 11.3 procedures per 1,000 enrollees included Honolulu (3.7); Asheville, North Carolina (4.9); Reno, Nevada (5.1); Danville, Pennsylvania (5.4); and Buffalo, New York (5.8).

Figure 11. Rates of PCI Among Hospital Referral Regions, 2003


PCI d

isch

arg

es p

er 1

,000

Med

icar

e en

rolle

es (2

003)




Ratio of Rates of PercutaneousCoronary Interventions to theU.S. Average

by Hospital Referral Region (2003)Map 2. Percutaneous Coronary Interventions

In 42 hospital referral regions, rates of PCI were at least 30% higher than the United States average of 11.3 per 1,000 Medicare enrollees. In 53 hospital referral regions, rates were more than 25% lower than the national average.



0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Redding HRR

California average

areas of interest

Coronary Artery Bypass Grafting Surgery in Redding, California

In 1996, we reported that the rate of coronary artery bypass grafting among residents of the Redding, California HRR in 1992-93 was 7.4 per 1,000 Medicare enrollees. That rate was 42% higher than the national average of 5.2 pro-cedures per 1,000 enrollees. When the next edition of the Atlas was published in 1998 (reporting 1994-95 data), the rate of bypass surgery in the Redding HRR had increased to 9.0 per 1,000 enrollees. At that time, the national average rate was 5.7 per 1,000 enrollees, and rates of the procedure in other California HRRs ranged from 3.7 in the Santa Rosa HRR to 6.8 in the Napa HRR.

The 1999 edition of the Dartmouth Atlas reported that the rate of CABG surgery in the Redding HRR in 1995-96 had climbed to 11.5 per 1,000 Medicare enrollees (a 55% increase over the rate in 1992-93), while the national aver-age rate had grown by only 19%, to 6.2 per 1,000 enrollees. Rates of CABG in other California HRRs in 1995-96 ranged from 3.6 per 1,000 enrollees in the Santa Rosa HRR to 7.0 per 1,000 in the Salinas HRR. The 1999 edition of the Atlas pointed out that the Redding HRR had had the highest rate of bypass grafting surgery in the United States in 1995-96.

The table beneath the graph gives the rates of coronary artery bypass grafting surgery per 1,000 Medicare enroll-ees in the Redding HRR and in California from 1992 to 2003. The rate remained essentially constant throughout the state between 1992 and 2003, rising from 4.9 proce-

Figure 12. Trends in Rates of Bypass Surgery in the Redding HRR and in California

CA

BG

dis

char

ges

per

1,0

00

Med

icar

e en

rolle

es

6.8 7.7 7.7 10.2 12.1 10.7 10.1 10.5 11.5 12.8 12.5 4.5

4.9 4.8 5.1 5.3 5.6 5.5 5.4 5.3 5.2 5.0 4.7 4.0

81 123 111 209 278 223 200 227 277 349 352 22

27 5 10 1 1 2 2 2 2 1 1 227

Number of procedures in excess of CA average

U.S. rank in year



dures per 1,000 in 1992 to 5.6 procedures in 1996, and then declining to 4.0 procedures in 2003. In the Redding HRR, however, rates of CABG surgery, which were about 40% higher than the state average in 1992, rose sharply between 1994 and 1996, to 12.1 per 1,000 Medicare enrollees, or more than twice the California average. After declining slightly in 1997 and 1998, rates in the Redding HRR rose again between 1998 and 2001, when the rate in Redding was 12.8 per 1,000 Medicare enrollees, or two and a half times higher than the state average. The national average rate of CABG per 1,000 Medicare enrollees in 2001 was 5.9, and in 2003 it declined to 5.2.

The table also gives the Redding HRR’s national ranking in rates of coronary artery bypass grafting during the decade 1992-2003 and estimates the number of procedures in excess of the California state average during the time peri-od. In 1992, Redding’s rate of CABG ranked 27th among 306 HRRs in the United States. By 1995, Redding ranked 1st; and remained the highest-rate or second-highest-rate HRR in the country until 2002. In 2003, the Redding HRR ranked 227th among the 306 HRRs.

Had the rate of CABG in the rest of California prevailed in the Redding HRR, 81 fewer procedures would have been done in 1992. In 1994, had the state rate prevailed, 111 fewer procedures would have been done; and in 2001, 349 fewer procedures would have been done had the rate in Redding been the same as the rate in the rest of Califor-nia. Between 1992 and 2003, there would have been 2,450 fewer CABG procedures among residents of the Redding HRR had the California average rate prevailed during the entire period.



0.0

10.0

20.0

30.0

40.0

50.0

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Elyria HRR

Ohio average

Percutaneous Coronary Interventions in Elyria, Ohio

We reported in 1996 that the rate of percutaneous coronary interventions among residents of the Elyria, OH HRR in 1992-93 was 9.1 per 1,000 Medicare enrollees. That rate was 86% higher than the national average of 4.9 procedures per 1,000 enrollees. The 1999 edition of the Dartmouth Atlas reported that the rate of PCI in the Elyria HRR in 1995-96 had climbed to 16.9 per 1,000 Medicare enrollees (an 86% increase over the rate in 1992-93), while the national average rate had grown by 35%, to 6.6 per 1,000 enrollees.

Rates of the procedure in other Ohio HRRs ranged from 5.7 in the Cleveland HRR to 8.3 in the Dayton HRR in 1995-96. The 1999 edition of the Atlas pointed out that the Elyria HRR had the highest rate of PCI in the United States in 1995-96.

The table beneath the graph gives the rates of PCI per 1,000 Medicare enrollees in the Elyria HRR and in Ohio from 1992 to 2003. The rate rose steadily throughout the state between 1992 and 2003, rising from 5.0 procedures per 1,000 in 1992 to 9.0 procedures in 1998, and reaching 13.5 procedures per 1,000 by 2003. In the Elyria HRR, rates of PCI, which were about 80% higher than the state average in 1992, rose much more sharply between 1993 and 1998, from 9.1 to 23.8 procedures per 1,000 Medicare enrollees, or more than two and a half times the Ohio average. After declining slightly in 1999, rates in the Elyria HRR rose again between 1999 and 2003, when the rate in Elyria reached 42.0 per 1,000 Medicare enrollees, more than three times higher than the state average. The national average rate of PCI per 1,000 Medicare enrollees in 2003 was 11.3.

Figure 13. Trends in Rates of PCI in the Elyria HRR and in Ohio

PCI d

isch

arg

es p

er 1

,000

M

edic

are

enro

llees

9.1 9.1 12.3 14.8 18.9 20.8 23.8 22.7 26.9 29.1 33.9 42.0

5.0 5.3 6.2 6.6 7.5 8.4 9.0 9.5 10.3 11.2 12.0 13.5

117 111 180 245 336 344 388 340 432 479 605 810

11 16 5 2 1 2 1 1 1 1 1 1

Number of procedures in excess of OH average

U.S rank in year



The table also gives the Elyria HRR’s national ranking in rates of PCI during the decade 1992-2003 and estimates the number of procedures in excess of the Ohio state aver-age during the time period. In 1992, Elyria’s rate of PCI ranked 11th among the 306 HRRs in the United States. By 1996, Elyria ranked 1st; and remained the highest-rate or second-highest-rate HRR in the country through 2003. Had the rate of PCI in the rest of Ohio prevailed in the Elyria HRR, 117 fewer procedures would have been done in 1992. In 1998, had the state rate prevailed, 388 fewer procedures would have been done; and in 2003, 810 fewer proce-dures would have been done had the rate in Elyria been the same as the rate in the rest of Ohio. Between 1992 and 2003, there would have been 4,388 fewer PCI procedures among residents of the Elyria HRR had the Ohio average rate prevailed during the entire period.



0.50

0.75

1.00

1.25

1.50

1.75

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

0.0

0.5

1.0

1.5

2.0

2.5

3.0

0.0 0.5 1.0 1.5 2.0 2.5 3.0

R2 = 0.23

Aortic and Mitral Valve ReplacementNational Trends in Utilization

Rates of aortic and mitral valve replacement increased about 33% from 1992 to 2003, from 1.05 procedures per 1,000 Medicare enrollees to 1.39 (Figure 14). Rates of valve replacement in 1992-93 were somewhat predictive of rates in 2002-03 (R2 = .23); 23% of the variation in rates in 2002-03 was predicted by the variation in 1992-93 (Figure 15). Rates of valve replacement were not correlated with the supply of cardiovascular surgeons per 100,000 residents in 1999 (R2 = .01) (figure not shown).

Figure 14. Trends in Rates of Aortic and Mitral Valve Replacement, 1992-2003

U.S

. ave

rag

e d

isch

arg

e ra

te

of v

alve

rep

lace

men

t p

er

1,00

0 M

edic

are

enro

llees

Figure 15. The Relationship Between Rates of Valve Replacement in 1992-03 and 2002-03

Aortic/mitral valve replacement discharges per 1,000 Medicare enrollees (1992-93)

Ao

rtic

/mit

ral v

alve

rep

lace

men

t d

isch

arg

es p

er 1

,000

Med

icar

e en

rolle

es (2

002-

03)

The 45 degree line represents equality between rates; if the dot representing an HRR is located above the line, enrollees in that HRR experienced higher rates of utilization in 2002-03 than in 1992-93.



0.4

0.8

1.2

1.6

2.0

2.4

2.8

Regional Variations in Rates of Aortic and Mitral Valve Replacement

Rates of valve replacement varied more than fourfold among Medicare enrollees in 2002-03 (Figure 16), from 0.6 procedures per 1,000 Medicare enrollees to 2.5. Among the hospital referral regions where rates of valve replacement were highest were Stockton, California (2.5); Johnstown, Pennsylvania (2.4); Marshfield, Wisconsin (2.3); Hudson, Florida (2.1); and East Long Island, New York (2.1). Regions with rates lower than the national average of 1.4 proce-dures per 1,000 enrollees included Honolulu (0.6); Muncie, Indiana (0.7); Kingsport, Tennessee (0.7); Greensboro, North Carolina (0.8); and Fort Worth, Texas (0.9).

Figure 16. Rates of Valve Replacement Among Hospital Referral Regions, 2002-03


Ao

rtic

/mit

ral v

alve

rep

lace

men

t p

er 1

,000

M

edic

are

enro

llees

(200

2-03

)




Ratio of Rates of Aortic/Mitral ValveReplacement to the U.S. Averageby Hospital Referral Region (2002-03)

Map 3. Aortic and Mitral Valve Replacement

In 32 hospital referral regions, rates of aortic and mitral valve replacement were at least 30% higher than the United States average of 1.4 per 1,000 Medicare enrollees. In 38 hospital referral regions, rates were more than 25% lower than the national average.



0.0

0.5

1.0

1.5

2.0

2.5

3.0

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Redding HRR

California average

AreAs of Interest

Aortic and Mitral Valve Replacement in Redding, California

In 1999, when the Dartmouth Atlas of Cardiovascular Health Care was published, we reported that rates of aortic valve replacement among Medicare patients had approximately doubled between 1988 and 1997, from 0.49 to 0.97 per 1,000 enrollees. Much of this increase was due to surgery rates in the very elderly. During this period, rates of aortic valve replacement among enrollees over age 75 increased 150% (from 0.20 to 0.50 per 1,000 enrollees). Rates among enrollees age 65 to 75 rose 57%, from 0.30 to 0.47 per 1,000 enrollees.

We also reported in 1999 that the rate of valve replace-ment surgery among residents of the Redding, California HRR in 1996-97 was 1.5 per 1,000 Medicare enrollees. That rate was about 66% higher than the national average of 0.9 procedures per 1,000 enrollees.

The rate of valve replacement surgery per 1,000 Medicare enrollees rose slightly throughout California between 1992 and 2003, rising from 1.2 procedures in 1992 to 1.5 procedures in 1998, and then declining to 1.3 per 1,000 enrollees in 2003. In the Redding HRR, however, rates of valve replacement surgery, which were slightly higher than the state average in 1992, rose sharply from 1995 to 1996, to 2.2 procedures per 1,000 Medicare enrollees. The rate of valve replacement surgery in the Redding HRR reached a high of 2.8 per 1,000 Medicare enrollees in 2000. This rate was twice the California average of 1.4 procedures per 1,000 enrollees in that year. The national average rate in

Figure 17. Trends in Rates of Valve Replacement in the Redding HRR and in California

Ao

rtic

/mit

ral v

alve

rep

lace

men

t d

isch

arg

es p

er 1

,000

Med

icar

e en

rolle

es1.4 1.4 1.1 1.4 2.2 2.2 2.5 2.5 2.8 2.4 2.2 1.1

1.2 1.2 1.2 1.3 1.3 1.4 1.5 1.5 1.4 1.4 1.4 1.3

7 11 -4 5 38 35 43 46 59 45 35 -9

19 16 102 47 1 2 2 1 1 3 8 236

Number of procedures in excess of CA average

U.S rank in year



2000 was 1.4 per 1,000 Medicare enrollees, or about half the rate in the Redding HRR.

The table beneath the graph gives the Redding HRR’s national ranking in rates of valve replacement surgery dur-ing the decade 1992-2003 and estimates the number of procedures in excess of the California state average during the time period. In 1992, the Redding HRR’s rate of valve replacement surgery ranked 19th among 306 HRRs in the United States. In 1994, it ranked 102nd. In 1996, Redding ranked 1st in the United States; it was 2nd in 1997 and 1998; 1st in 1999 and 2000; 3rd in the country in 2001, 8th in 2002, and 236th in 2003.

Had the rate of valve replacement surgery in the rest of California prevailed in the Redding HRR, seven fewer pro-cedures would have been done in 1992. In 1994, had the state rate prevailed, four more procedures would have been done; and in 2000, 59 fewer procedures would have been done had the rate in Redding been the same as the rate in the rest of California. Between 1992 and 2003, there would have been 311 fewer valve replacement procedures in the Redding HRR had the California average rate pre-vailed during the entire period.



MethodsHospital referral regions (HRRs) are aggregations of hospital service areas (HSAs). A hospital service area is a collection of Zip codes whose residents receive most of their hospitalizations from the hospitals within that area. Hospital referral regions represent regional health care markets for tertiary medical care; each HRR contains at least one hospital that performs major cardiovascular procedures and neurosurgery.

The Medicare population in an area that was used as the denominator for the rates in these studies included those alive, age 65 to 99, and not enrolled in a risk bearing HMO. The numerator for the surgical rates pre-sented was based on all individuals meeting these eligibility criteria who underwent the specified procedure during an inpatient stay within the given year, based on the ICD-9-CM procedure codes shown in the table.

Rates based on a count of fewer than 11 observed counts are not displayed for reasons of patient confidentiality. Rates with fewer than 26 expected events are reported in parentheses to indicate lack of statistical precision; the margin of error is greater than 20%. In the case of aortic and mitral valve replacement, two-year rates are shown to increase the sample size. Rates were adjusted to the age, sex and race distribution of the national Medicare population as follows. The national event rate for each age-sex-race category was computed. These rates were then applied to the HSA and HRR populations to produce the expected number of events in the HSA or HRR; that is, the number of events that would have occurred in the HSA if its rate had been the same as the national event rate.

PROCEDURE PROCEDURE CODES

Coronary artery bypass grafting (CABG) 36.10-36.19

Percutaneous coronary interventions 36.01-36.02, 36.05, 36.06, 36.07, 36.09

Coronary angiography 37.22, 37.23, 88.55-88.57

Aortic/mitral valve replacement 35.2-35.24



HRR City Medicare enrollees (2003) CABG Discharges per 1,000 Medicare Enrollees

PCI Discharges per 1,000 Medicare Enrollees

Aortic/Mitral Valve Replacement Discharges per 1,000

Medicare Enrollees

1992 2003 1992 2003 92-93 02-03

AL-Birmingham 248,416 8.0 7.0 7.6 16.4 1.03 1.33

AL-Dothan 48,312 6.4 5.5 5.6 10.7 1.01 1.12

AL-Huntsville 65,697 7.1 5.0 5.2 10.9 0.86 1.04

AL-Mobile 83,047 7.5 9.5 6.0 16.3 1.28 1.94

AL-Montgomery 50,310 4.8 6.7 9.9 11.6 0.70 1.42

AL-Tuscaloosa 29,474 7.1 5.5 5.7 17.2 0.64 0.83

AK-Anchorage 37,952 4.2 4.9 1.9 6.5 0.93 1.43

AZ-Mesa 62,906 4.5 5.9 3.9 12.7 0.96 1.31

AZ-Phoenix 213,665 4.3 4.5 4.4 13.8 1.03 1.15

AZ-Sun City 45,768 4.3 5.0 6.9 15.6 1.03 1.55

AZ-Tucson 96,644 4.1 4.2 5.6 10.8 0.94 1.27

AR-Fort Smith 45,401 5.4 5.0 3.2 9.7 0.74 1.20

AR-Jonesboro 30,774 7.1 5.4 7.3 12.8 0.90 0.78

AR-Little Rock 196,877 7.4 7.1 3.7 14.8 1.08 1.29

AR-Springdale 51,746 4.5 5.5 4.4 10.2 0.65 1.58

AR-Texarkana 33,719 7.8 6.7 1.7 12.2 0.74 1.02

CA-Orange County 166,864 4.9 3.6 5.8 9.8 1.02 1.09

CA-Bakersfield 61,042 5.7 6.1 7.1 14.3 1.56 1.74

CA-Chico 40,936 5.0 4.6 4.8 7.0 1.28 1.73

CA-Contra Costa County 55,617 6.3 4.4 6.2 7.4 1.55 1.25

CA-Fresno 75,758 4.2 5.0 3.9 11.9 0.84 1.54

CA-Los Angeles 491,457 4.8 3.5 5.6 9.6 1.10 1.21

CA-Modesto 59,030 6.0 5.6 6.0 6.8 1.18 1.50

CA-Napa 31,135 6.7 6.5 11.5 13.5 1.27 1.75

CA-Alameda County 75,811 4.1 2.9 7.2 10.0 0.94 0.84

CA-Palm Springs/Rancho Mira 35,583 5.0 4.7 6.1 13.2 1.56 1.70

Age-Sex-Race Adjusted Rates of Cardiac Surgery Among Medicare Enrollees by U.S. Hospital Referral Region






Medicare Enrollees

1992 2003 1992 2003 92-93 02-03

CA-Redding 45,814 6.8 4.5 5.1 5.8 1.41 1.63

CA-Sacramento 156,321 5.9 4.9 4.9 6.9 1.52 1.76

CA-Salinas 36,264 4.8 4.4 10.1 10.5 1.51 1.82

CA-San Bernardino 104,375 4.3 3.9 4.9 8.4 0.94 1.22

CA-San Diego 185,883 4.3 3.4 4.8 10.7 1.23 1.31

CA-San Francisco 99,210 4.1 3.0 3.8 8.4 0.98 1.03

CA-San Jose 84,693 4.8 3.1 5.4 9.9 1.50 1.12

CA-San Luis Obispo 27,496 4.2 4.2 3.7 6.5 0.91 1.31

CA-San Mateo County 54,603 3.9 3.1 5.3 10.1 1.22 1.31

CA-Santa Barbara 38,380 4.3 4.5 5.0 6.6 0.99 1.21

CA-Santa Cruz 20,121 3.9 3.7 6.6 8.5 1.32 1.30

CA-Santa Rosa 37,988 4.1 4.2 6.6 7.0 1.36 1.87

CA-Stockton 38,085 5.7 6.6 12.8 10.8 1.27 2.53

CA-Ventura 55,755 4.4 4.9 4.9 11.1 1.08 1.44

CO-Boulder 15,829 3.2 4.3 3.1 11.0 0.70 1.44

CO-Colorado Springs 64,549 4.8 3.4 4.8 7.4 0.94 1.27

CO-Denver 138,091 3.2 3.2 4.7 10.2 0.80 1.15

CO-Fort Collins 27,738 4.5 3.6 6.3 11.9 1.10 1.19

CO-Grand Junction 35,679 2.0 1.9 3.3 6.1 0.58 1.08

CO-Greeley 30,805 5.0 3.5 4.0 9.4 0.92 1.25

CO-Pueblo 18,456 3.6 2.3 3.1 4.7 0.93 0.93

CT-Bridgeport 73,280 3.9 3.3 5.1 10.2 1.10 1.29

CT-Hartford 187,110 5.8 5.4 3.6 7.6 1.28 1.83

CT-New Haven 169,453 5.5 4.6 5.5 8.8 1.38 1.74

DE-Wilmington 81,536 4.8 5.7 5.9 9.9 0.83 1.90

DC-Washington 241,879 4.7 5.2 5.0 10.9 1.01 1.26






Medicare Enrollees

1992 2003 1992 2003 92-93 02-03

FL-Bradenton 48,559 6.0 5.5 4.0 14.5 1.35 1.40

FL-Clearwater 75,578 4.9 5.0 5.1 17.9 1.33 1.88

FL-Fort Lauderdale 294,689 6.6 4.9 6.5 11.5 1.46 1.75

FL-Fort Myers 186,081 5.5 4.9 5.1 11.8 1.18 1.47

FL-Gainesville 61,506 5.8 5.0 4.0 14.8 0.89 0.98

FL-Hudson 68,157 7.3 6.1 4.6 17.9 1.48 2.11

FL-Jacksonville 144,231 6.8 6.0 5.7 14.3 1.09 1.51

FL-Lakeland 44,364 5.2 4.7 7.4 12.9 1.02 1.54

FL-Miami 172,985 4.7 3.4 4.6 10.3 1.17 1.35

FL-Ocala 107,392 6.7 5.6 5.4 14.7 1.04 1.78

FL-Orlando 402,543 5.6 6.5 6.0 13.9 0.96 1.55

FL-Ormond Beach 51,206 5.0 5.7 5.6 10.2 0.80 1.49

FL-Panama City 26,492 4.9 8.0 5.4 13.1 0.95 1.38

FL-Pensacola 90,772 6.4 5.9 4.6 14.2 1.02 1.29

FL-Sarasota 98,170 6.9 5.8 5.5 11.6 1.40 1.65

FL-St. Petersburg 53,341 4.6 4.5 3.8 9.8 1.36 1.58

FL-Tallahassee 78,191 4.9 5.0 3.0 9.6 0.83 0.91

FL-Tampa 96,192 5.8 5.5 5.0 11.3 1.18 1.22

GA-Albany 22,318 4.6 4.6 1.6 9.9 1.02 1.07

GA-Atlanta 390,727 5.3 4.8 6.5 11.1 0.89 1.04

GA-Augusta 68,764 5.1 6.0 9.1 14.2 0.95 1.27

GA-Columbus 34,943 5.7 4.0 4.9 7.2 0.91 0.74

GA-Macon 76,452 6.4 7.9 6.1 18.4 0.87 1.12

GA-Rome 32,791 7.9 7.0 7.7 21.0 0.73 1.21

GA-Savannah 80,865 6.5 4.6 5.0 11.1 0.97 1.22

HI-Honolulu 134,785 3.2 2.3 3.6 3.7 0.89 0.60






Medicare Enrollees

1992 2003 1992 2003 92-93 02-03

ID-Boise 71,139 4.1 3.1 3.9 9.0 0.83 0.95

ID-Idaho Falls 19,661 3.8 4.3 2.8 9.2 1.11 1.10

IL-Aurora 16,962 5.7 4.3 3.7 9.4 0.84 1.03

IL-Blue Island 99,503 5.8 6.8 5.4 13.0 1.04 1.38

IL-Chicago 209,621 5.2 5.1 4.7 13.0 0.92 1.27

IL-Elgin 54,539 4.6 5.7 5.5 12.1 0.81 1.58

IL-Evanston 125,606 5.7 4.3 5.8 11.0 1.15 1.28

IL-Hinsdale 38,593 7.7 4.7 5.7 11.0 1.10 1.66

IL-Joliet 59,768 8.1 6.7 5.0 13.8 1.03 1.34

IL-Melrose Park 132,651 6.4 5.5 5.0 12.3 1.27 1.43

IL-Peoria 88,652 6.1 4.0 5.8 10.4 1.01 1.04

IL-Rockford 88,638 4.2 6.1 5.6 10.3 0.94 1.75

IL-Springfield 124,713 5.9 5.4 5.1 14.9 1.02 1.26

IL-Urbana 50,684 5.1 6.2 4.3 13.7 0.88 1.22

IL-Bloomington 17,990 8.2 6.7 3.4 13.3 1.04 1.19

IN-Evansville 96,860 5.7 5.8 5.0 7.9 0.85 1.27

IN-Fort Wayne 104,209 4.9 5.0 5.7 10.3 1.03 1.09

IN-Gary 60,975 7.0 6.3 6.3 9.9 1.15 1.21

IN-Indianapolis 306,172 4.6 4.8 7.1 11.0 0.90 1.22

IN-Lafayette 23,372 5.3 3.7 6.9 12.9 1.19 1.07

IN-Muncie 22,475 5.0 4.4 6.6 9.2 1.19 0.70

IN-Munster 38,991 6.7 7.3 11.0 16.0 0.73 1.85

IN-South Bend 84,006 6.0 5.6 3.0 9.1 1.12 1.39

IN-Terre Haute 24,628 5.0 5.8 9.3 12.8 0.89 1.41

IA-Cedar Rapids 37,334 7.4 5.3 3.6 13.1 1.35 1.65

IA-Davenport 69,921 5.4 4.2 4.2 20.8 1.00 1.40






Medicare Enrollees

1992 2003 1992 2003 92-93 02-03

IA-Des Moines 138,413 5.3 5.1 8.5 13.7 0.87 1.13

IA-Dubuque 23,063 3.8 4.2 6.0 10.5 0.66 0.99

IA-Iowa City 40,477 5.8 5.2 3.3 8.8 1.02 1.01

IA-Mason City 25,420 5.9 6.5 4.5 9.8 1.33 1.55

IA-Sioux City 37,895 3.4 3.5 4.8 7.6 0.74 1.00

IA-Waterloo 31,203 4.7 5.8 3.1 13.6 1.14 1.68

KS-Topeka 56,883 4.2 3.6 6.4 10.5 0.65 1.15

KS-Wichita 171,229 5.8 7.6 5.9 14.4 1.05 1.71

KY-Covington 34,294 6.3 7.1 3.7 11.8 0.79 1.58

KY-Lexington 162,584 5.6 7.2 3.0 13.2 0.81 1.32

KY-Louisville 192,527 6.3 6.4 4.2 9.9 0.98 1.43

KY-Owensboro 18,737 6.9 7.5 4.2 8.9 0.85 1.29

KY-Paducah 55,985 6.3 6.3 3.8 11.9 0.83 1.03

LA-Alexandria 34,389 4.6 8.4 9.9 22.9 0.67 1.35

LA-Baton Rouge 65,323 5.6 6.4 5.9 7.8 0.84 1.22

LA-Houma 26,669 6.8 5.3 8.5 17.6 0.99 1.25

LA-Lafayette 60,433 5.6 6.1 8.9 27.5 0.98 1.90

LA-Lake Charles 30,520 4.0 3.6 6.4 11.4 0.86 0.86

LA-Metairie 38,948 6.4 8.1 7.8 21.7 0.94 1.53

LA-Monroe 33,793 6.0 6.9 3.7 19.1 0.80 1.19

LA-New Orleans 51,896 6.4 4.8 7.3 10.2 0.98 1.32

LA-Shreveport 83,770 4.8 5.4 5.8 14.9 0.68 1.20

LA-Slidell 17,032 6.4 6.6 4.5 19.8 1.29 1.61

ME-Bangor 59,106 4.4 5.3 3.2 10.1 0.76 1.45

ME-Portland 138,212 4.8 4.5 4.5 8.5 0.76 1.29

MD-Baltimore 276,169 5.6 5.4 5.0 12.4 1.01 1.33






Medicare Enrollees

1992 2003 1992 2003 92-93 02-03

MD-Salisbury 62,943 4.7 5.9 7.0 13.1 0.82 1.78

MD-Takoma Park 75,644 4.2 4.5 6.6 11.6 0.80 1.12

MA-Boston 486,231 4.6 3.7 3.7 8.6 1.11 1.31

MA-Springfield 79,305 4.0 3.9 2.7 6.0 1.08 1.45

MA-Worcester 49,966 4.3 3.9 2.7 12.4 1.07 1.36

MI-Ann Arbor 141,641 5.2 5.1 5.9 10.8 1.09 1.36

MI-Dearborn 65,539 6.9 6.1 5.7 13.6 0.85 1.33

MI-Detroit 210,810 5.8 5.0 5.4 15.5 0.97 1.26

MI-Flint 61,116 7.1 8.2 5.0 11.9 0.90 2.03

MI-Grand Rapids 123,482 4.5 5.0 3.3 11.1 0.75 1.60

MI-Kalamazoo 81,206 5.4 5.1 8.6 18.2 0.97 1.44

MI-Lansing 78,012 6.3 5.4 4.4 14.8 1.43 1.72

MI-Marquette 32,300 5.0 6.3 4.1 10.4 0.94 1.40

MI-Muskegon 35,582 4.8 4.9 3.4 8.0 0.85 1.51

MI-Petoskey 27,851 5.9 6.1 5.6 15.2 1.34 2.03

MI-Pontiac 42,357 5.5 4.6 5.5 14.1 0.93 1.59

MI-Royal Oak 84,804 5.8 4.5 6.1 14.0 0.93 1.23

MI-Saginaw 95,948 6.6 7.0 8.1 17.5 1.10 1.47

MI-St. Joseph 19,896 5.6 5.2 9.4 23.4 1.07 1.51

MI-Traverse City 37,234 6.8 6.5 5.2 12.0 1.08 2.37

MN-Duluth 51,885 3.6 4.9 3.5 14.6 1.10 1.50

MN-Minneapolis 308,272 4.3 4.1 4.5 10.6 1.05 1.48

MN-Rochester 57,215 4.0 4.5 5.2 9.5 1.26 1.91

MN-St. Cloud 28,221 4.4 3.1 4.3 12.4 1.14 1.45

MN-St. Paul 83,198 4.1 4.2 4.6 9.8 0.79 1.49

MS-Gulfport 20,927 4.9 5.3 3.5 20.9 0.64 1.05






Medicare Enrollees

1992 2003 1992 2003 92-93 02-03

MS-Hattiesburg 33,499 4.1 7.3 4.6 17.8 0.71 1.84

MS-Jackson 118,515 4.3 5.0 2.8 8.5 0.57 1.12

MS-Meridian 26,221 3.9 8.2 2.9 11.1 0.66 1.59

MS-Oxford 17,900 5.6 6.0 4.8 9.4 0.77 1.40

MS-Tupelo 46,234 4.8 7.9 2.2 11.3 0.62 1.45

MO-Cape Girardeau 37,415 5.0 7.7 7.2 11.8 0.86 1.41

MO-Columbia 88,805 7.0 6.0 7.5 16.2 1.00 1.40

MO-Joplin 50,260 4.8 5.7 6.4 17.7 1.05 1.45

MO-Kansas City 230,811 5.3 5.3 6.8 12.5 0.80 1.18

MO-Springfield 104,773 5.1 5.2 9.0 13.5 1.22 1.59

MO-St. Louis 336,036 6.3 6.3 5.4 13.8 1.15 1.50

MT-Billings 67,187 5.2 4.8 4.5 8.9 1.23 1.26

MT-Great Falls 20,594 4.4 5.0 6.3 10.3 0.86 1.86

MT-Missoula 47,123 3.9 3.3 9.3 13.6 1.37 1.91

NE-Lincoln 77,539 5.0 8.2 3.2 14.3 0.81 2.09

NE-Omaha 146,406 4.9 5.9 5.0 11.7 1.18 1.60

NV-Las Vegas 108,814 5.4 4.3 5.4 10.9 1.03 1.07

NV-Reno 66,752 4.1 3.2 3.5 5.1 1.11 1.14

NH-Lebanon 57,019 3.4 3.7 2.2 8.2 1.04 1.44

NH-Manchester 93,283 5.6 5.0 3.6 6.7 1.22 1.87

NJ-Camden 341,259 5.1 4.4 4.0 11.5 1.22 1.70

NJ-Hackensack 142,107 4.8 4.9 3.9 10.6 1.26 1.95

NJ-Morristown 108,231 4.4 4.9 3.9 9.4 1.11 1.79

NJ-New Brunswick 99,910 4.9 5.3 5.0 11.8 1.13 1.68

NJ-Newark 143,345 4.8 5.9 4.5 13.6 1.19 1.80

NJ-Paterson 38,734 4.5 4.8 4.2 11.7 1.09 1.96






Medicare Enrollees

1992 2003 1992 2003 92-93 02-03

NJ-Ridgewood 45,150 5.1 5.0 3.1 10.0 1.52 2.00

NM-Albuquerque 129,743 2.8 3.2 2.9 6.5 0.70 1.13

NY-Albany 218,243 5.3 4.5 2.3 6.9 1.25 1.63

NY-Binghamton 55,475 4.7 5.4 3.4 7.7 0.92 1.65

NY-Bronx 73,104 3.5 3.5 2.5 7.6 0.91 1.30

NY-Buffalo 136,013 4.8 4.9 1.6 5.8 0.69 1.19

NY-Elmira 51,069 5.1 5.9 3.5 11.4 1.05 1.83

NY-East Long Island 434,131 4.5 4.9 3.5 12.1 1.36 2.10

NY-Manhattan 344,145 4.3 3.8 2.8 10.1 1.19 1.48

NY-Rochester 116,092 4.7 4.5 2.4 10.3 0.99 1.77

NY-Syracuse 134,228 3.6 5.7 2.7 10.3 1.18 1.97

NY-White Plains 117,427 3.8 4.0 2.5 8.3 1.08 1.62

NC-Asheville 101,103 4.0 4.7 2.3 4.9 0.98 1.16

NC-Charlotte 211,801 4.7 4.6 5.0 10.3 0.71 1.16

NC-Durham 151,095 6.0 5.6 4.5 9.7 1.08 1.11

NC-Greensboro 60,053 5.5 5.2 7.1 9.2 0.98 0.77

NC-Greenville 94,736 5.7 5.8 4.8 8.7 1.01 1.37

NC-Hickory 34,873 4.8 4.9 4.0 11.6 0.82 0.93

NC-Raleigh 152,776 5.4 6.4 4.6 12.2 0.90 1.33

NC-Wilmington 50,251 5.8 5.8 4.3 6.9 0.93 1.59

NC-Winston-Salem 113,666 5.4 4.4 4.6 11.5 0.84 1.33

ND-Bismarck 31,721 6.0 6.9 3.9 11.2 0.66 1.17

ND-Fargo/Moorhead MN 71,438 4.8 6.7 4.3 9.3 1.05 1.62

ND-Grand Forks 23,119 5.8 5.2 3.7 23.0 1.08 1.42

ND-Minot 18,929 7.2 4.6 5.8 18.1 0.63 1.36

OH-Akron 69,860 6.7 4.7 6.1 11.1 1.07 1.42






Medicare Enrollees

1992 2003 1992 2003 92-93 02-03

OH-Canton 71,773 5.1 7.1 3.3 12.9 0.99 1.84

OH-Cincinnati 157,809 5.8 4.8 5.2 12.6 0.98 1.29

OH-Cleveland 258,997 5.9 5.5 4.1 12.4 0.99 1.45

OH-Columbus 293,949 4.7 6.8 5.7 14.1 0.96 1.46

OH-Dayton 129,204 6.7 7.0 6.0 14.1 0.95 1.34

OH-Elyria 28,440 6.2 4.5 9.1 42.0 1.15 1.76

OH-Kettering 45,083 5.8 4.7 4.6 11.7 0.94 1.38

OH-Toledo 107,919 3.9 6.3 3.9 12.7 0.86 1.50

OH-Youngstown 83,550 5.7 7.0 4.0 9.2 0.96 1.79

OK-Lawton 24,272 5.4 6.4 4.3 16.2 0.72 1.68

OK-Oklahoma City 201,498 5.8 6.3 6.0 17.6 0.87 1.25

OK-Tulsa 134,030 4.4 4.5 5.3 11.4 0.76 1.04

OR-Bend 18,591 3.9 3.8 6.5 5.6 1.23 1.24

OR-Eugene 87,006 4.0 4.4 3.6 7.2 1.09 1.69

OR-Medford 68,308 4.5 4.8 2.4 6.9 1.19 1.59

OR-Portland 151,496 4.5 3.7 3.9 7.8 1.05 1.43

OR-Salem 17,699 4.2 4.9 4.3 7.0 0.88 0.93

PA-Allentown 143,938 5.3 5.4 4.4 10.8 1.18 1.73

PA-Altoona 34,898 6.2 6.4 2.1 14.1 1.35 2.17

PA-Danville 67,646 4.4 4.7 3.0 5.4 1.19 1.52

PA-Erie 96,259 4.7 6.3 4.1 8.8 1.04 1.87

PA-Harrisburg 127,146 5.1 4.6 4.9 11.2 1.16 1.74

PA-Johnstown 24,625 6.4 6.7 4.6 16.2 1.42 2.43

PA-Lancaster 74,911 6.0 5.7 5.8 10.6 1.32 1.56

PA-Philadelphia 327,894 5.5 4.4 4.3 9.8 1.17 1.50

PA-Pittsburgh 309,328 5.7 6.7 5.5 11.7 1.15 1.85






Medicare Enrollees

1992 2003 1992 2003 92-93 02-03

PA-Reading 72,172 5.9 4.9 5.2 11.7 1.27 1.39

PA-Sayre 28,067 4.0 5.8 2.7 9.7 0.84 1.73

PA-Scranton 48,097 4.7 5.8 3.6 9.9 1.11 1.87

PA-Wilkes-Barre 40,734 5.6 7.6 2.2 10.9 0.87 1.70

PA-York 53,714 4.6 3.5 2.7 8.8 0.81 0.94

RI-Providence 103,268 4.3 4.2 3.0 7.5 0.99 1.32

SC-Charleston 103,410 5.2 6.6 4.8 9.4 0.76 1.51

SC-Columbia 123,318 6.0 5.4 4.9 13.2 0.75 0.94

SC-Florence 40,961 5.4 5.5 7.4 8.2 0.77 0.96

SC-Greenville 99,834 5.8 5.5 3.4 13.0 0.87 1.05

SC-Spartanburg 45,132 4.2 5.1 3.6 6.8 0.75 0.78

SD-Rapid City 25,814 5.1 3.8 3.4 8.8 0.76 1.19

SD-Sioux Falls 114,752 5.5 4.8 5.2 10.0 1.13 1.30

TN-Chattanooga 79,026 6.0 7.8 3.5 12.3 0.94 1.38

TN-Jackson 45,875 7.3 6.0 3.9 13.2 0.87 1.07

TN-Johnson City 30,824 4.4 5.8 3.8 11.0 0.82 1.25

TN-Kingsport 59,817 3.8 3.8 3.1 7.6 0.84 0.70

TN-Knoxville 153,553 5.6 6.0 4.1 10.9 0.72 1.07

TN-Memphis 180,335 7.9 7.1 5.8 14.1 0.83 1.12

TN-Nashville 246,112 5.8 5.8 3.2 9.0 0.80 1.44

TX-Abilene 43,198 6.3 6.0 4.9 15.7 0.68 1.18

TX-Amarillo 52,691 5.4 6.3 3.5 15.5 0.75 1.16

TX-Austin 100,938 4.8 4.3 4.5 12.8 0.91 1.18

TX-Beaumont 54,505 7.3 8.1 5.1 11.8 0.95 1.71

TX-Bryan 20,928 6.4 9.3 4.7 10.7 1.07 1.53

TX-Corpus Christi 52,089 6.3 5.8 4.8 8.5 0.91 1.10






Medicare Enrollees

1992 2003 1992 2003 92-93 02-03

TX-Dallas 315,706 5.1 5.2 6.4 10.7 0.91 1.18

TX-El Paso 99,545 4.6 4.2 4.3 9.8 0.81 1.00

TX-Fort Worth 140,176 5.3 5.1 3.5 11.3 0.71 0.91

TX-Harlingen 47,306 5.6 6.7 4.4 10.7 0.84 0.90

TX-Houston 411,882 5.6 5.1 5.3 12.0 0.89 1.27

TX-Longview 25,160 5.0 5.8 4.2 8.6 0.79 1.21

TX-Lubbock 77,959 5.8 7.2 10.2 14.4 0.85 1.27

TX-McAllen 42,672 7.2 9.1 6.9 18.4 0.93 1.39

TX-Odessa 35,751 5.5 7.7 6.5 11.2 0.66 1.20

TX-San Angelo 21,373 5.9 7.3 3.4 8.2 0.68 1.14

TX-San Antonio 198,667 4.9 5.2 2.8 8.3 0.61 1.13

TX-Temple 38,121 4.9 4.8 3.8 10.9 0.56 1.15

TX-Tyler 73,677 5.3 7.3 5.5 9.6 0.80 1.53

TX-Victoria 20,257 3.7 3.3 2.9 14.2 0.86 1.15

TX-Waco 41,846 4.4 5.5 3.3 9.0 0.64 0.93

TX-Wichita Falls 28,033 4.4 4.7 2.9 9.6 0.75 1.11

UT-Ogden 34,000 5.6 4.2 3.6 8.6 1.27 1.82

UT-Provo 31,402 5.3 4.6 7.7 18.5 1.66 1.14

UT-Salt Lake City 156,464 4.5 4.4 3.8 8.4 1.34 1.58

VT-Burlington 75,570 5.6 5.0 2.6 10.1 1.11 1.59

VA-Arlington 138,055 4.0 3.9 4.4 7.2 0.76 1.23

VA-Charlottesville 67,600 3.3 3.2 3.9 9.0 0.87 1.14

VA-Lynchburg 35,339 5.9 4.8 2.2 6.5 1.06 1.08

VA-Newport News 60,793 5.5 5.1 5.2 9.5 0.86 1.17

VA-Norfolk 124,400 7.1 5.6 4.6 10.1 1.02 1.48

VA-Richmond 172,152 6.0 4.8 6.9 10.9 1.13 1.31






Medicare Enrollees

1992 2003 1992 2003 92-93 02-03

VA-Roanoke 97,178 5.2 4.8 2.6 9.6 0.91 1.22

VA-Winchester 46,516 5.2 5.5 4.6 13.6 0.97 1.19

WA-Everett 43,697 5.5 3.6 2.9 6.9 1.25 1.07

WA-Olympia 32,811 5.3 4.2 7.3 10.7 1.65 1.71

WA-Seattle 208,641 4.7 3.6 4.5 7.5 1.22 1.40

WA-Spokane 165,187 5.2 4.8 4.1 7.0 1.32 1.88

WA-Tacoma 56,957 5.1 4.2 3.1 9.9 1.10 1.40

WA-Yakima 29,098 4.3 4.2 3.3 10.2 0.76 1.75

WV-Charleston 125,914 6.0 7.1 3.8 10.9 0.76 1.25

WV-Huntington 50,842 4.8 6.5 2.9 17.3 0.71 0.96

WV-Morgantown 53,264 4.8 4.7 5.1 12.5 0.87 0.98

WI-Appleton 40,207 4.7 4.7 5.4 9.0 0.92 1.40

WI-Green Bay 67,207 4.4 5.0 2.7 7.7 0.80 1.44

WI-La Crosse 40,499 4.7 6.1 3.3 7.6 1.29 2.05

WI-Madison 119,503 4.9 4.1 3.9 10.1 0.96 1.24

WI-Marshfield 52,987 5.0 7.2 3.1 9.7 1.33 2.32

WI-Milwaukee 286,730 6.0 6.1 8.2 14.4 1.23 1.79

WI-Neenah 31,339 6.2 4.7 4.6 11.5 0.90 1.67

WI-Wausau 27,574 4.9 8.1 5.0 10.4 1.05 2.31

WY-Casper 23,836 4.5 5.0 4.0 10.6 1.22 1.50

US-United States 28,767,985 5.3 5.2 4.9 11.3 1.03 1.41

Documents

Cardiac Surgery