Sequential events contributing to variations in cardiac revascularization rates

Numerous studies have demonstrated the importance of race, payor, and gender in determining the use of cardiac services, including revascularization procedures (bypass surgery and angioplasty). However, there has been less investigation into where and when in the process of care differences in utilization arise. In this report, the authors examined the sequence of events leading to the use of revascularization procedures, identifying four phases of care (prehospital, intrahospital, interhospital, and posthospital). Following a cohort of 5857 patients admitted to California hospitals with acute myocardial infarction in 1991, the authors found differences in treatment probabilities during nearly every phase for different racial and payor groups. For example, compared with patients who are uninsured, patients with private insurance were more likely to be admitted initially to a hospital offering revascularization (adjusted odds ratio [OR] = 1.40, 95% confidence interval [CI] 1.30 to 1.51). Moreover, once admitted to such a hospital, private patients were more likely to undergo revascularization (adjusted OR = 2.30; 95% CI 1.80 to 2.94). They were also more likely to undergo transfer to receive revascularization (adjusted OR = 1.22; 95% CI 1.03 to 1.45), and to be readmitted for revascularization (adjusted OR = 1.60; 95% CI 1.13 to 2.27). Previously reported discrepancies in service use represent the cumulative effects of multiple phases during which different racial and payor groups experience different processes of care.     

Access and outcomes of elderly patients enrolled in managed care

OBJECTIVE: To determine differences in access to care and medical outcomes for Medicare patients with an acute or a chronic symptom who were enrolled in health maintenance organizations (HMOs) compared with similar fee-for-service (FFS) nonenrollees. DESIGN: A 1990 household telephone survey of Medicare beneficiaries who reported joint pain or chest pain during the previous 12 months. SAMPLE: Stratified random sample of HMO enrollees (n = 6476) and comparable sample of FFS Medicare beneficiaries (n = 6381). ACCESS AND OUTCOME MEASURES: Care-seeking behavior, physician visits, diagnostic procedures performed, therapeutic interventions prescribed, follow-up recommended by a physician, and symptom response to treatment. RESULTS: After controlling for demographic factors, health and functional status, and health behavior characteristics, HMO enrollees with joint pain (n = 2243) were more likely than nonenrollees (n = 2009) to have a physician visit (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.03 to 1.38) and medication prescribed (OR, 1.35; 95% CI, 1.14 to 1.60). Patients with chest pain who were enrolled in HMOs (n = 556) were less likely than nonenrollees (n = 524) to have a physician visit (OR, 0.50; 95% CI, 0.30 to 0.82). For both joint and chest pain, HMO enrollees were less likely to see a specialist for care, have follow-up recommended, or have their progress monitored. There were no differences in complete elimination of symptoms, but HMO enrollees with continued joint pain reported less symptomatic improvement than nonenrollees (OR, 0.72; 95% CI, 0.59 to 0.86). CONCLUSIONS: Reduced utilization of services for patients with specific ambulatory conditions was observed in HMOs with Medicare risk contracts, with less symptomatic improvement in one of the four outcomes studied.     

The impact of payor/provider type on health care use and expenditures among the frail elderly

OBJECTIVES: This study examined whether health care expenditures and usage by the frail elderly differ under three payor/provider types: Medicare fee for service, Medicare health maintenance organization (HMO), and dual Medicare-Medicaid enrollment. METHODS: In-home interviews were conducted among 450 frail elderly patients of a San Diego, Calif, health care system. Cost and use data were collected from providers. RESULTS: Analyses revealed no difference in total expenditures between fee-for-service and HMO enrollees, but Medicare-Medicaid beneficiaries' expenditures were 46.8% higher than those for HMO enrollees and 52.2% higher than those for the fee-for-service group. Fee-for-service participants were less than half as likely as HMO enrollees to have two or more hospital admissions, but hospital usage rates between those two payor/provider groups did not differ. Not were there payor/provider differences in access to home health care, but HMO home health care users received significantly fewer services than the others. CONCLUSIONS: The care provided to these HMO beneficiaries resulted in a combination of restricted home health use and higher multiple hospitalizations. This raises compelling questions for future research. For the dually enrolled, stronger cost containment may be required.     

How do HMOs achieve savings? The effectiveness of one organization's strategies

OBJECTIVE: To examine how a group practice used organizational strategies rather than provider-level incentives to achieve savings for health maintenance organization (HMO) compared to fee-for-service (FFS) patients. DATA SOURCES/STUDY SETTING: A large group practice with a group model HMO also treating FFS patients. Data sources were all patient encounter records, demographic files, and clinic records covering 3.5 years (1986-1989). The clinic's procedures to record services and charges were identical for FFS and HMO patients. All FFS and HMO patients under age 65 who received any outpatient services during approximately 100,000 episodes of the seven study illnesses were eligible. STUDY DESIGN: Using an explanatory case design, we first compared HMO and FFS rates of resource utilization, in standardized dollars, which measured the impact of organizational strategies to influence patient and provider behavior. We then examined the effect of HMO insurance and organizational measures to explain total outpatient use. Key variables were standardized charges for all outpatient services and the HMO's strategies. PRINCIPAL FINDINGS: Patient and provider behavior responded to organizational strategies designed to achieve savings for HMO patients; for instance, HMO patients used midlevel providers and generalists more often and ER and specialists less often. Overall HMO savings, adjusted for case mix, were explained by the specialty of the physicians the patients first visited and appeared to affect patients with average health more than others. CONCLUSION: Organizational strategies, without resort to differential financial incentives to each provider, resulted in lower rates of outpatient services for HMO patients. Savings from outpatient use, especially for common diseases that rarely require hospitalization, can be substantial.     

Long-term outcome in acute myocardial infarction patients admitted to hospitals with and without on-site cardiac catheterization facilities. MITI Investigators. Myocardial Infarction Triage and Intervention

BACKGROUND: Previous studies have documented the strong association between availability of on-site cardiac catheterization facilities and increased use of coronary angiography in patients with acute myocardial infarction (AMI). Although these studies have shown little influence of the availability of catheterization labs on hospital mortality, no long-term follow-up has been reported. METHODS AND RESULTS: From a cohort of 12,331 AMI patients admitted to 19 Seattle area hospitals, we compared long-term outcome in 7985 patients admitted to hospitals with and 4346 patients admitted to hospitals without on-site catheterization labs. During the index hospitalization, patients admitted to hospitals with on-site catheterization were more likely to undergo coronary angiography (67.1% versus 39.3%, P<.0001), coronary angioplasty (32.5% versus 13.2%, P<.0001), or coronary bypass surgery (12.5% versus 9.5%, P<.0001). At 3-year follow-up, patients admitted to hospitals with on-site catheterization labs were more likely to undergo postdischarge angiography (19.2% versus 15.2%, P=.0001) and coronary angioplasty (11.6% versus 8.2%, P<.0001). This was associated with approximately $2500.00 per patient in higher cumulative costs. Despite this higher rate of procedure use, there was no association between admission to a hospital with on-site catheterization facilities and lower long-term mortality (multivariate hazard ratio, 1.0; 95% CI, 0.93 to 1.1., the hazard being associated with admission to hospitals with on-site catheterization facilities). CONCLUSIONS: In an urban area with unconstrained patient transfer mechanisms and high overall cardiac procedure use rates, AMI patients admitted to hospitals without on-site catheterization facilities were managed with fewer procedures during hospitalization and follow-up. This more conservative treatment approach was not associated with any observed increase in long-term mortality.     

Management and outcomes for black patients with acute myocardial infarction in the reperfusion era. National Registry of Myocardial Infarction 2 Investigators

Data from a national registry of myocardial infarction patients from June 1994 to April 1996 were analyzed to compare the presenting characteristics, acute reperfusion strategies, treatment patterns, and clinical outcomes among black and white patients. Blacks presented much later to the hospital after the onset of symptoms (median 145 vs 122 minutes, p <0.001), were more likely to have atypical cardiac symptoms (28% vs 24%, p <0.001), and nondiagnostic electrocardiograms during the initial evaluation period compared with whites (37% vs 31%, p <0.001). Also, blacks were less likely to receive intravenous thrombolytic therapy (adjusted odds ratio [OR] 0.76, 95% confidence intervals [CI] 0.71 to 0.80), coronary arteriography (adjusted OR 0.85, 95% CI 0.77 to 0.95), other elective catheter-based procedures (adjusted OR 0.87, 95% CI 0.78 to 0.96), and coronary artery bypass surgery (adjusted OR 0.66, 95% CI 0.58 to 0.75) than their white counterparts. Despite these differences in treatment, there were no significant differences in hospital mortality between blacks and whites.     

Effects of toothbrush design and brushing proficiency on plaque removal

BACKGROUND: Primary care physicians frequently use antibiotics for nonindicated conditions and conditions for which antibiotics have not been shown to be effective. The intention of this study was to determine whether shifting the costs from the insurer to physicians in a staff model health maintenance organization (HMO) influenced antibiotic prescribing. METHODS: A random sample of patients in whom upper respiratory infections (URIs) (n = 334) or acute bronchitis (n = 218) were diagnosed within a 12-month period was selected from a large multispecialty group practice whose population was predominantly fee-for-service (FFS) and from a staff model HMO. Detailed chart reviews were performed to verify the diagnosis and note secondary diagnoses, identify whether an antibiotic or other medication was prescribed, assess whether diagnostic testing was performed, and determine the specialty of the clinician. RESULTS: After excluding patients seen with sinusitis, otitis media, or streptococcal pharyngitis, 334 patients with URIs and 218 patients with acute bronchitis remained for analysis. For URIs, antibiotic prescribing was higher in the HMO population than in the FFS group (31% vs 20%, P = .02). In patients with acute bronchitis, HMO patients were also more likely to have an antibiotic prescribed, but the difference was not statistically significant (82% vs 73%, P = .11). Further analyses showed that while HMO physicians were more likely to prescribe antibiotics, they were less likely to prescribe other medications for acute bronchitis or use diagnostic tests for evaluation of patients with URIs or bronchitis. CONCLUSIONS: Shifting costs from insurer to physicians through managed care appears to reduce diagnostic testing for URIs and acute bronchitis, but does not decrease excessive use of antibiotics and may actually increase antibiotic use for URIs.     

Patterns of increased in vivo fundus autofluorescence in the junctional zone of geographic atrophy of the retinal pigment epithelium associated with age-related macular degeneration

BACKGROUND: The impact of upper endoscopy in patients with upper gastrointestinal hemorrhage treated in community practice is unknown. Thus we examined the effectiveness of endoscopy performed within 24 hours of admission (early endoscopy). METHODS: Medical records of 909 consecutive hospitalized patients with upper gastrointestinal hemorrhage who underwent endoscopy at 13 hospitals in a large metropolitan area were reviewed. We evaluated unadjusted and severity-adjusted associations of early endoscopy with recurrent bleeding or surgery to control hemorrhage, length of hospital stay, and associations of endoscopic therapy in patients with bleeding ulcers or varices. RESULTS: Early endoscopy was performed in 64% of patients and compared with delayed endoscopy and was associated with clinically significant reductions in adjusted risk of recurrent bleeding or surgery (odds ratio [OR] 0.70: 95% CI [0.44, 1.13]) and a 31% decrease in adjusted length of stay (95% CI: [24%, 37%]). In patients at high risk for recurrent bleeding, the use of early endoscopic therapy to control hemorrhage was associated with reductions in recurrent bleeding or surgery (OR 0.21: 95% CI [0.10, 0.47]) and length of stay (-31%: 95% CI [-44%, -14%). CONCLUSION: In this study of community-based practice, the routine use of endoscopy, and in selected cases endoscopic therapy, performed early in the clinical course of patients with upper gastrointestinal hemorrhage was associated with reductions in length of stay and, possibly, the risk of recurrent bleeding and surgery.     

Permanent cardiac pacing after a cardiac operation: predicting the use of permanent pacemakers

BACKGROUND: The need for permanent cardiac pacing after cardiac operations is infrequent but associated with increased morbidity and resource utilization. We identified patient risk factors for pacemaker insertion to enable development of a predictive model. METHODS: Data were collected prospectively for 10,421 consecutive patients who had cardiac operations between January 1990 and December 1995. Two hundred fifty-five patients (2.4%) were identified as having received a permanent pacemaker during the same hospitalization. Logistic regression analysis was performed to determine the independent, multivariate predictors of permanent pacing. The predictive accuracy and precision of the logistic regression model was evaluated in the 1996 database of 2,236 consecutive patients by the calculation of Brier scores. RESULTS: Eight independent predictors of permanent pacemaker requirement were identified. The factor-adjusted odds ratios (OR) with 95% confidence interval (CI) associated with each predictor are as follows: (1) valve replacement surgery (aortic: OR 5.8, CI 3.9-8.7; mitral: OR 4.9, CI 3.1-7.8; tricuspid: OR 8.0, CI 5.5-11.9; double: OR 8.9, CI 5.5-14.6; and triple: OR 7.5, CI 2.9-19.3); (2) repeat operation: OR 2.4, CI 1.8-3.3; (3) age 75 years or older: OR 3.0, CI 2.0-4.4; (4) ablative arrhythmia operation: OR 4.2, CI 1.9-9.5; (5) mitral valve annular reconstruction: OR 2.4, CI 1.4-4.2; (6) use of cold blood cardioplegia: OR 2.0, CI 1.2-3.6; (7) preoperative renal failure: OR 1.6, CI 1.0-2.6; and (8) active endocarditis: OR 1.7, CI 0.9-3.0. A model for postoperative permanent pacemaker requirement using the eight predictors was formulated and tested (Brier score = 0.017+/-0.003; Z = 0.18). CONCLUSIONS: The proposed predictive model correlated highly with actual pacemaker use, which suggests that the requirement for pacing results from either operative trauma or increased ischemic burden. Preoperative identification of patients at increased risk of conduction disturbances may allow for earlier detection and improved treatment. Patients requiring postoperative pacing had increased morbidity and length of stay.     

Risk factors for septic arthritis in patients with joint disease. A prospective study

OBJECTIVE: To quantify potential risk factors for septic arthritis, in order to identify a basis for prevention. METHODS: The occurrence of potential risk factors for septic arthritis in patients with joint diseases attending a rheumatic disease clinic was prospectively monitored at 3-month intervals over a period of 3 years. Potential risk factors investigated were type of joint disease, comorbidity, medication, joint prosthesis, infections, and invasive procedures. The frequencies of risk factors in patients with and those without septic arthritis were compared using multiple logistic regression analysis. RESULTS: There were 37 patients with and 4,870 without septic arthritis. Risk factors for developing septic arthritis were age > or = 80 years (odds ratio [OR] = 3.5, 95% confidence interval [95% CI] 1.4-8.6), diabetes mellitus (OR = 3.3, 95% CI 1.1-10.1), rheumatoid arthritis (OR = 4.0, 95% CI 1.9-8.3), hip and/or knee prosthesis (OR = 15, 95% CI 4.1-54.3), joint surgery (OR = 5.1, 95% CI 2.2-11.9), and skin infection (OR = 27.2, 95% CI 7.6-97.1). CONCLUSION: These findings indicate that preventive measures against septic arthritis in patients with joint diseases should mainly be directed at those with joint prostheses and/or skin infection.     

Effects of different protective agents on the phototoxicity of fluoranthene to Daphnia magna

OBJECTIVE: To determine if a risk prediction model for patients with unstable angina would predict resource utilization. METHODS AND RESULTS: Four hundred sixty-five consecutive patients admitted for unstable angina to a tertiary care university-based medical center were prospectively evaluated from June 1, 1992, to June 30, 1995. The proportion of patients receiving coronary angiography, coronary angioplasty, and coronary artery bypass grafting were analyzed according to four risk groups on the basis of a previously published model: Group 1, <2% risk of major complication; Group 2, 2.1% to 5% risk; Group 3, 5.1 % to 15% risk; and Group 4, >15.1 % risk. Hospital length of stay and estimated cost of hospitalization based on DRG and specific payer ratio of cost-to-charge were also compared between groups. Multiple linear regression analysis was used to determine the influence of estimated risk and procedures on hospital costs. The four groups were well matched for gender, hypertension, tobacco history, and previous percutaneous transluminal coronary angioplasty and myocardial infarction. Group 4 had a higher incidence of previous coronary bypass grafting (35% vs 10%, p=0.001) and triple vessel or left main coronary artery disease compared with Group 1 (44% vs 13%, p=0.041). Group 4 patients were more likely to be admitted to the coronary care unit compared with Group 2 or Group 1 patients (80% vs Group 1: 51% [p= 0.001]; and vs Group 2: 53% [p=0.001]), more likely to receive heparin (87% vs 71%, p=0.007), and more likely to receive a beta-blocker or calcium channel blocker (89% vs 74%, p=0.008) than Group 1. Coronary angioplasty rates were similar for all groups, but Group 4 patients were more likely to receive coronary bypass grafting than Group 2 or Group 1 (27% vs Group 2: 12%, p=0.004 and vs Group 1: 8%, p=0.002). Hospital length of stay was highest in Group 4 and lowest for Group 1. Average hospital costs were significantly less in Group 3 than in Group 4, but higher than in Group 1. Multivariate analysis determined a dependency of costs on risk group with Group 2 having costs 31.4% (95% CI=9.8 to 57.2), Group 3 46.7% (24, 3 to 73.1), and Group 4 75% (46.9 to 110.7) higher than Group 1. The use of procedures also significantly increased costs, with PTCA-treated patients having a 44.9% (26.7 to 65.7) increase in costs compared with medically treated patients, and surgically treated patients having a 204.7% increase in costs. CONCLUSION: Resource utilization as assessed by the use of revascularization procedures, length of stay, and hospital costs are influenced by patient acuity estimated from a prediction model on the basis of estimated risk of cardiac complications. The model exerts independent influence on cost even after adjustment for various procedures. The use of revascularization procedures, especially coronary artery surgery, remains a large determinant of hospital cost.     

Regional variation across the United States in the management of acute myocardial infarction. GUSTO-1 Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries

BACKGROUND: Differences in the management of acute myocardial infarction have been reported among countries, but few studies have investigated this issue in regions of the United States. METHODS: We compared the management of acute myocardial infarction among census regions across the United States, using data from the first Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries trial (GUSTO-1) comprising 21,772 patients, and from the American Hospital Association. RESULTS: We found substantial regional variation in the management of acute myocardial infarction in the United States. Beta-blockers (prescribed for a range of 55 to 81 percent of patients in the various regions), nitrates (prescribed for 61 to 77 percent), and angiotensin-converting-enzyme inhibitors (prescribed for 18 to 23 percent) were used most often in New England, whereas calcium-channel blockers (31 to 42 percent) and lidocaine (14 to 43 percent) were used least often there. Similarly, the proportion of patients undergoing various cardiac procedures differed among regions (range for angiography, 52 to 81 percent of patients; angioplasty, 22 to 35 percent; and coronary-artery bypass surgery, 9 to 17 percent) and was lowest in New England. The regional use of cardiac procedures was closely related to their availability, except in New England. After the analysis was adjusted for clinical and hospital variables, patients in New England were found to be less likely to undergo angiography than patients in the other regions (odds ratio, 0.37; 95 percent confidence interval, 0.32 to 0.42). There was no apparent relation between the use of cardiac procedures and rates of recurrent infarction or death at 30 days or 1 year. CONCLUSIONS: There is substantial regional variation in the use of cardiac medications and procedures to manage acute myocardial infarction in the United States. The use and availability of cardiac procedures are closely related. The management of acute myocardial infarction in New England is atypical in that the relatively limited availability of cardiac procedures does not account for their relatively low use in that region.     

Antiarrhythmic therapies for the prevention of sudden cardiac death

Despite remarkable advances in cardiovascular therapeutics, sudden cardiac death remains a significant problem. In this review, data from clinical trials and other studies on antiarrhythmic therapies have been evaluated in order to determine effective strategies for the prevention of sudden cardiac death in high risk patients. Overall, routine prophylactic use of class I antiarrhythmic agents in high risk patients, mostly survivors of acute myocardial infarction, is associated with increased risk of death [61 trials, 23,486 patients: odds ratio (OR) 1.13; 95% confidence interval (CI) 1.01 to 1.27, p < 0.05]. Conversely, beta-blockers are associated with highly significant reductions in risk of death in postinfarction patients (56 trials, 53,521 patients: OR 0.81; 95% CI 0.75 to 0.87, p < 0.00001). Overall data from the amiodarone trials on high risk patients, including postinfarction patients, patients with congestive heart failure or survivors of cardiac arrest, suggest that this agent is effective in reducing the risk of death (14 trials, 5713 patients: OR 0.83; 95% CI 0.72 to 0.95, p = 0.01) although further studies are needed to better define which types of patients will potentially benefit most from this agent. No benefits were seen with calcium channel blockers (26 trials, 21,644 patients: OR 1.03; 95% CI 0.94 to 1.13, p = NS). The implantable cardioverter-defibrillator is a promising option for high risk patients, but definition of its role awaits the completion of ongoing clinical trials. Since causes of sudden death are heterogeneous, the clinician should pursue a multifactorial approach to its prevention. Primary and secondary prevention of cardiac ischaemia, through the treatment of cardiovascular risk factors and maximising the use of aspirin, beta-blockers, lipid-lowering drugs, and angiotensin converting enzyme inhibitors after acute myocardial infarction, should lead to a future decrease in the incidence of sudden cardiac death.     

The relationship between clinical tooth status and receipt of sealants among child Medicaid recipients

This study investigated the association between caries status and sealant need at a prior survey and subsequent sealant use in a Medicaid program. Clinical data from a 1986-87 statewide epidemiological survey (N = 8026) representative of North Carolina (NC) schoolchildren (grades K-12) were linked with all NC Medicaid dental claims submitted during 1987-92, yielding 570 children in the survey who had at least one dental visit during 1987-1992. From the 570, 390 children were included: 71 who received sealants (S) and 319 who received non-sealant care (NS). Children were excluded based on age, having preexisting sealants, or having no sealant-eligible molars or premolars. S and NS were compared on baseline dfs, DMFS, and sealant need, controlling for the patient's age, number of visits, and the provider's propensity to seal. At all ages, NS was twice as likely to have had prior dfs or DMFS (OR = 2.04, 95% CI = 1.15, 3.70). The association between sealant receipt and prior sealant need varied by age. At 6 to 11 years, S and NS had equal likelihood of sealant need (OR = 1.41, 95% CI = 0.62, 3.18). At 12 to 15 years, NS had a greater likelihood of sealant need (OR = 6.82, 95% CI = 1.60, 29.08). Caries-free status was associated with subsequent sealant receipt. Prior sealant need caused variability in dentists' decisions, depending on the child's age and past caries experience. Sealants were used infrequently by most providers and for a minority of patients. These findings are important for the Medicaid program and for future non-randomized studies of sealant effectiveness.     

Prognostic factors and etiology in patients with severe community-acquired pneumonia admitted at the ICU. Spanish multicenter study. Study Group on Severe Community-Acquired Pneumonia in Spain

OBJECTIVE: To determine the techniques used for the etiological diagnosis of community-acquired pneumonia in patients admitted to the intensive care unit (ICU) and to describe the predominant causative organisms as well as prognostic factors of ICU mortality. PATIENTS AND METHODS: A total of 262 patients with community-acquired pneumonia admitted to 26 ICUs between 1 November of 1991 and 31 October of 1992 were included in a prospective, open, multicenter study. RESULTS: The diagnostic techniques most frequently used were blood culture (243 cases) and simple tracheal aspirate (166 cases). Simple tracheal aspirate (58.4%), bronchoalveolar lavage (47.7%), and protected-specimen brush (44.2%) were the techniques that showed the highest diagnostic reliability. In 220 cases, techniques considered of high diagnostic probability were employed. With the use of these procedures, the most frequent causative pathogens were Streptococcus pneumoniae (13.6%) and Legionella pneumophila (9.5%). In 100 cases (45.5%), no pathogen was isolated. A total of 88 patients (33.6%) died during the ICU stay. Predictive variables of poor outcome selected by means of a multivariate analysis were as follows: multisystemic failure (OR = 28.6; 95% CI: 12.8-65.1; p = 0.0001), APACHE II at the time of ICU admission (OR = 5.3; 95% CI: 2.5-11.3; p = 0.0001), progression and/or spread of lung infection (OR = 4.5; 95% CI: 2.4-8.4; p = 0.0001), and shock on admission (OR = 8.48; 95% CI: 4.5-15.9; p = 0.0001). CONCLUSIONS: In 45.5% of patients with community-acquired pneumonia admitted to ICU, no causative pathogen was identified. The prognosis of these patients was influenced by the severity of disease assessed by APACHE II score and presence of multisystemic failure and shock at the time of ICU admission.     

The importance of continuity of care in the likelihood of future hospitalization: is site of care equivalent to a primary clinician?

OBJECTIVES: This study examined the effect of continuity with clinicians and health care sites on likelihood of future hospitalization. METHODS: Delaware Medicaid patient data were analyzed. Logistic regression models supplied adjusted effects of continuity on hospitalization. RESULTS: Patients in the high clinician continuity group had lower odds of hospitalization than patients in the high site/low clinician continuity group (odds ratio [OR] = 0.75, 95% confidence interval [CI] = 0.66, 0.87). The latter group did not differ from the low site/low clinician continuity group (OR = 0.93, 95% CI = 0.80, 1.08). CONCLUSIONS: A location providing health care without clinician continuity may not be sufficient to ensure cost-effective care.     

Value of acute rest sestamibi perfusion imaging for evaluation of patients admitted to the emergency department with chest pain

OBJECTIVES: This study sought to determine the ability of early perfusion imaging using technetium-99m sestamibi to predict adverse cardiac outcomes in patients who present to the emergency department with possible cardiac ischemia and nondiagnostic electrocardiograms (ECGs). BACKGROUND: Evaluation of patients presenting to the emergency department with possible acute coronary syndromes and nondiagnostic ECGs is problematic. Accurate risk stratification is necessary to prevent serious adverse outcomes. Initial results suggest that early perfusion imaging using technetium-99m sestamibi enables reliable risk stratification. METHODS: Patients presenting to the emergency department with a low to moderate probability of acute coronary syndromes underwent rapid sestamibi injection with gated single-photon emission computed tomographic imaging. Studies showing perfusion defects with associated wall motion abnormalities were considered positive. RESULTS: A total of 532 consecutive patients underwent serial myocardial marker analysis and rest perfusion imaging. Of these patients, perfusion imaging was positive in 171 (32%). Positive perfusion imaging was the only multivariate predictor of myocardial infarction (MI) (p < 0.0001, odds ratio [OR] 33, 95% confidence interval [CI] 7.7 to 141) and was the most important independent predictor of MI or revascularization (p < 0.0001, OR 14, 95% CI 7.3 to 25), followed by diabetes (p < 0.01, OR 2.8, 95% CI 1.5 to 5.1), typical angina (p = 0.01, OR 2.1, 95% CI 1.2 to 3.7) and male gender (p = 0.03, OR 1.9, 95% CI 1.1 to 3.5). The sensitivity of positive perfusion imaging for MI was 93% (95% CI 77% to 98%), and for MI or revascularization it was 81% (95% CI 71% to 88%), with negative predictive values of 99% (95% CI 98% to 100%) and 95% (95% CI 92% to 97%), respectively. CONCLUSIONS: Positive rest perfusion imaging accurately identified patients at high risk for adverse cardiac outcomes, whereas negative perfusion imaging identified a low risk patient group. Early perfusion imaging allows for rapid and accurate risk stratification of emergency department patients with possible cardiac ischemia and nondiagnostic ECGs.     

Is coronary angiography necessary for vascular surgery patients who have positive results of dipyridamole thallium scans?

PURPOSE: Because dipyridamole thallium (DT) scanning is a useful predictor of perioperative cardiac events, a positive results of a DT scan is frequently the basis for performing more invasive cardiac evaluation and for consideration for performing coronary revascularization procedures before performing peripheral vascular surgery. The rationale for this approach has been that the treatment of anatomically significant coronary artery disease would lower the risk of performing a subsequent vascular operation. However, the benefit of performing aggressive diagnostic and therapeutic cardiac procedures in such patients remains unproved. To examine this issue, data from patients who underwent coronary angiography because of thallium redistribution were compared with data from matched control subjects who underwent peripheral vascular operations without further cardiac evaluation. METHODS: The medical records of 70 consecutive patients who underwent coronary angiography because of the presence of two or more segments of redistribution on DT scan were reviewed and compared with 70 other patients matched with respect to age, gender, peripheral vascular operation, and number of segments of redistribution on DT scan who did not undergo additional cardiac evaluation. RESULTS: DT scans were performed on 934 preoperative peripheral vascular surgery patients to help in the assessment of operative risk. Ischemic responses, defined as two or more segments of redistribution, were observed in 297. Of these, 70 underwent cardiac catheterization and 25 underwent coronary revascularization procedures. Adverse outcomes affected 46% of the coronary angiography group and 44% of the control group (p = NS). Patients who underwent coronary angiography and were considered for myocardial revascularization had fewer cardiac events with a subsequent vascular operation than did the control subjects. However, any possible benefit from invasive cardiac evaluation was offset by the three deaths and two myocardial infarctions (MIs) that complicated the cardiac evaluation. There was no significant difference between the angiography group and the matched control subjects with respect to perioperative nonfatal MI (13% vs 9%), fatal MI (4% vs 3%), late nonfatal MI (16% vs 19%), or late cardiac death (10% vs 13%). In long-term follow-up, MIs occurred later in patients who underwent coronary angiography than the control subjects (p = 0.049), but this difference was not associated with an improvement in the overall survival rate. CONCLUSIONS: The risks of extended cardiac evaluation and treatment did not produce any improvement in either the perioperative or the long-term survival rate. For most vascular surgery patients who have a positive result of a DT scan, coronary angiography does not provide any additional useful information.     

The impact of nosocomial infections on patient outcomes following cardiac surgery

STUDY OBJECTIVE: To evaluate the relationship between nosocomial infections and clinical outcomes following cardiac surgery, and to identify risk factors for the development of nosocomial infections in this patient population. DESIGN: Prospective cohort study. SETTING: Barnes-Jewish Hospital, St. Louis, a university-affiliated teaching hospital. PATIENTS: Six hundred five consecutive patients undergoing cardiac surgery. INTERVENTIONS: Prospective patient surveillance and data collection. MAIN OUTCOME MEASURES: Occurrence of nosocomial infections, multiorgan dysfunction, hospital mortality, and risk factors for the acquisition of nosocomial infections. RESULTS: One hundred thirty-one (21.7%) patients acquired at least one nosocomial infection following cardiac surgery. Four independent risk factors for the development of a nosocomial infection were identified: the duration of mechanical ventilation, postoperative empiric antibiotic administration, the duration of urinary tract catheterization, and female gender. Thirty (5.0%) patients died during their hospitalization. The mortality rate of patients acquiring a nosocomial infection (11.5%) was significantly greater than the mortality rate of patients without a nosocomial infection (3.2%) (odds ratio [OR]=4.0; 95% confidence interval [CI]=2.7 to 5.8; p<0.001). Multiorgan dysfunction was found to be the most important independent determinant of hospital mortality (adjusted OR=23.8; 95% CI=13.5 to 42.1; p<0.001) along with the aortic cross-clamp time (adjusted OR=2.3; 95% CI=1.7 to 3.0; p=0.002) and severity of illness as measured by APACHE II (acute physiology and chronic health evaluation) (adjusted OR=1.1; 95% CI=1.1 to 1.2; p=0.019). Ventilator-associated pneumonia, clinical sepsis, female gender, the cardiopulmonary bypass time, and severity of illness were identified as independent risk factors for the development of multiorgan dysfunction. Among hospital survivors, patients acquiring a nosocomial infection had longer hospital lengths of stay compared to patients without a nosocomial infection (20.1+/-13.0 days vs 9.7+/-4.5 days; p<0.001). CONCLUSIONS: Nosocomial infections, which are common following cardiac surgery, are associated with prolonged lengths of hospitalization, the development of multiorgan dysfunction, and increased hospital mortality. These data suggest potential interventions for the prevention of nosocomial infections following cardiac surgery that could substantially improve patient outcomes and decrease medical care costs.     

Differences in the effect of patients' socioeconomic status on the use of invasive cardiovascular procedures across health insurance categories

OBJECTIVES: This study evaluated the effect of patients' socioeconomic status on use of coronary angiography, bypass grafting, and angioplasty across health insurance categories. METHODS: Multiple logistic regression was used to compute the odds of receiving each procedure among 206 233 ischemic heart disease patients residing in urban California zip codes from 1991 through 1993. RESULTS: Residents of high socioeconomic status areas were more likely (odds ratios [ORs] = 1.20-1.41) and residents of low socioeconomic status areas were less likely (ORs = 0.79-0.84) than residents of middle socioeconomic status areas to undergo each procedure. These effects were common among Medicare and health maintenance organization patients and uncommon for privately insured and uninsured patients. CONCLUSIONS: The effect of socioeconomic status varies across health insurance categories.