Exclusive Articles
Study: Most Angioplasties Unneeded
NEW ORLEANS (AP) -- More than half a million people a year with chest pain are
getting an unnecessary or premature procedure to unclog their arteries because
drugs are just as effective, suggests a landmark study that challenges one of
the most common practices in heart care.
View full story here. (Washington Post)
Cardiology articles of interest
Study: Most Angioplasties Unneeded
NEW ORLEANS (AP) -- More than half a million people a year with chest pain are
getting an unnecessary or premature procedure to unclog their arteries because
drugs are just as effective, suggests a landmark study that challenges one of
the most common practices in heart care.
View full story here. (Washington Post)
First, a New Artery Stent Study; Now, Questions About What It All Means
By BARNABY J. FEDER | Published: March 28, 2007
NEW ORLEANS, March 27 — Is today the first in a new era for angioplasty and
stenting, the artery-clearing technology that enchanted doctors while giving
birth to a multibillion-dollar industry?
Many heart specialists at the annual scientific meeting here of the American
College of Cardiology said it ought to be, based on a report Monday that found
little additional value in giving stents to most heart patients as long as they
received the right medicines.
View full story here. (New York Times)
Young Doctors Find Specialist Jobs Hard to Get
By ELISABETH ROSENTHAL
Published: April 15, 1995.
View full story here. (New York Times)
Mortality among Patients Admitted to Hospitals on Weekends as Compared with
Weekdays
Chaim M. Bell, M.D., and Donald A. Redelmeier, M.D.
ABSTRACT
Background
The level of staffing in hospitals is often lower on weekends than on
weekdays, despite a presumably consistent day-to-day burden of disease. It is
uncertain whether in-hospital mortality rates among patients with serious
conditions differ according to whether they are admitted on a weekend or on a
weekday.
Methods
We analyzed all acute care admissions from emergency departments in
Ontario, Canada, between 1988 and 1997 (a total of 3,789,917 admissions). We
compared in-hospital mortality among patients admitted on a weekend with that
among patients admitted on a weekday for three prespecified diseases: ruptured
abdominal aortic aneurysm (5454 admissions), acute epiglottitis (1139), and
pulmonary embolism (11,686) and for three control diseases: myocardial
infarction (160,220), intracerebral hemorrhage (10,987), and acute hip fracture
(59,670), as well as for the 100 conditions that were the most common causes of
death (accounting for 1,820,885 admissions).
Results
Weekend admissions were associated with significantly higher
in-hospital mortality rates than were weekday admissions among patients with
ruptured abdominal aortic aneurysms (42 percent vs. 36 percent, P<0.001),
acute epiglottitis (1.7 percent vs. 0.3 percent, P=0.04), and pulmonary
embolism (13 percent vs. 11 percent, P=0.009). The differences in mortality
persisted for all three diagnoses after adjustment for age, sex, and coexisting
disorders. There were no significant differences in mortality between weekday
and weekend admissions for the three control diagnoses. Weekend admissions were
also associated with significantly higher mortality rates for 23 of the 100
leading causes of death and were not associated with significantly lower
mortality rates for any of these conditions.
Conclusions
Patients with some serious medical conditions are more likely to die
in the hospital if they are admitted on a weekend than if they are admitted on
a weekday.
View full story here. (New England Journal of Medicine)
Do "America's Best Hospitals" Perform Better for Acute Myocardial Infarction?
Jersey Chen, B.A., Martha J. Radford, M.D., Yun Wang, M.S., Thomas A.
Marciniak, M.D., and Harlan M. Krumholz, M.D.
ABSTRACT
Background
"America's Best Hospitals," an influential list published annually by
U.S. News & World Report, assesses the quality of hospitals. It is not
known whether patients admitted to hospitals ranked at the top in cardiology
have lower short-term mortality from acute myocardial infarction than those
admitted to other hospitals or whether differences in mortality are explained
by differential use of recommended therapies.
Methods
Using data from the Cooperative Cardiovascular Project on 149,177
elderly Medicare beneficiaries with acute myocardial infarction in 1994 or
1995, we examined the care and outcomes of patients admitted to three types of
hospitals: those ranked high in cardiology (top-ranked hospitals); hospitals
not in the top rank that had on-site facilities for cardiac catheterization,
coronary angioplasty, and bypass surgery (similarly equipped hospitals); and
the remaining hospitals (non–similarly equipped hospitals). We compared 30-day
mortality; the rates of use of aspirin, beta-blockers, and reperfusion; and the
relation of differences in rates of therapy to short-term mortality.
Results
Admission to a top-ranked hospital was associated with lower adjusted
30-day mortality (odds ratio, 0.87; 95 percent confidence interval, 0.76 to
1.00; P=0.05 for top-ranked hospitals vs. the others). Among patients without
contraindications to therapy, top-ranked hospitals had significantly higher
rates of use of aspirin (96.2 percent, as compared with 88.6 percent for
similarly equipped hospitals and 83.4 percent for non–similarly equipped
hospitals; P<0.01) and beta-blockers (75.0 percent vs. 61.8 percent and 58.7
percent, P<0.01), but lower rates of reperfusion therapy (61.0 percent vs.
70.7 percent and 65.6 percent, P=0.03). The survival advantage associated with
admission to top-ranked hospitals was less strong after we adjusted for factors
including the use of aspirin and beta-blockers (odds ratio, 0.94; 95 percent
confidence interval, 0.82 to 1.08; P=0.38).
Conclusions
Admission to a hospital ranked high on the list of "America's Best
Hospitals" was associated with lower 30-day mortality among elderly patients
with acute myocardial infarction. A substantial portion of the survival
advantage may be associated with these hospitals' higher rates of use of
aspirin and beta-blocker therapy.
View full story here. (New England Journal of Medicine)
Admission to Hospitals With On-Site Cardiac Catheterization Facilities
Impact on Long-Term Costs and Outcomes
Harlan M. Krumholz, MD; Jersey Chen, BA; Jaime E. Murillo, MD; David J.
Cohen, MD; ; Martha J. Radford, MD
From the Section of Cardiovascular Medicine, Department of Medicine (H.M.K.,
J.C., J.E.M.) and the Section of Chronic Disease Epidemiology, Department of
Epidemiology and Public Health (H.M.K.), Yale School of Medicine and the
Yale–New Haven Hospital Center for Outcomes Research and Evaluation (H.M.K.,
M.J.R.), New Haven, Conn; the Connecticut Peer Review Organization, Middletown
(H.M.K., M.J.R.); and the Beth Israel-Deaconess Medical Center, Department of
Medicine, Cardiovascular Division and the Harvard School of Public Health,
Boston, Mass (D.J.C.).
Background—Admission to a hospital with a capability for
cardiac procedures is associated with a higher likelihood of referral for a
cardiac procedure but not with a better short-term clinical outcome. Whether
there are differences in long-term mortality and resource consumption is not
clear. We sought to determine whether elderly Medicare patients with acute
myocardial infarction admitted to hospitals with on-site cardiac
catheterization facilities have lower long-term hospital costs and better
outcomes than patients admitted to hospitals without such facilities.
Methods and Results—As part of the Cooperative Cardiovascular
Project pilot in Connecticut, we conducted a retrospective cohort study using
data from medical charts and administrative files. The study sample included
2521 patients with acute myocardial infarction covered by Medicare from 1992 to
1993. The cardiac catheterization rate was higher in the hospitals with
facilities (38.6% versus 26.9%; P<0.001), but the revascularization rate was
similar (20.5% versus 19.5%) during the initial episode of care and at 3 years
(29.7% versus 29.7%). Mortality rates were similar for patients admitted to the
2 types of hospitals at 30 days (OR, 1.08; 95% CI, 0.83 to 1.42) and at 3 years
(OR, 1.02; 95% CI, 0.83 to 1.26). The adjusted readmission rates were
significantly lower among patients admitted to hospitals with cardiac
catheterization facilities (OR, 0.76; 95% CI, 0.61 to 0.94). However, the
overall mean days in the hospital for the 3 years after admission was 25.9 for
patients admitted to hospitals with facilities and 24.6 for the other patients
(P=0.234). Adjusting for baseline patient characteristics, there was no
significant difference in the 3-year costs between patients admitted to the 2
types of hospitals.
Conclusions—With higher rates of cardiac catheterization and lower readmission
rates, patients admitted to hospitals with on-site cardiac catheterization
facilities did not have significantly different hospital costs compared with
patients admitted to hospitals without these facilities. There was also no
significant difference in short- or long-term mortality rates.
View full story here. (AHA Circulation Journal)
Does physician specialty affect the survival of elderly patients with
myocardial infarction?
C D Frances, M G Shlipak, H Noguchi, P A Heidenreich, and M
McClellanDepartment of Medicine, University of California, San Francisco, USA.
Abstract
OBJECTIVE: To determine the effect of treatment by a
cardiologist on mortality of elderly patients with acute myocardial infarction
(AMI, heart attack), accounting for both measured confounding using
risk-adjustment techniques and residual unmeasured confounding with
instrumental variables (IV) methods.
DATA SOURCES/STUDY SETTING: Medical chart data and
longitudinal administrative hospital records and death records were obtained
for 161,558 patients aged > or =65 admitted to a nonfederal acute care
hospital with AMI from April 1994 to July 1995. Our principal measure of
significant cardiologist treatment was whether a patient was admitted by a
cardiologist. We use supplemental data to explore whether our analysis would
differ substantially using alternative definitions of significant cardiologist
treatment.
STUDY DESIGN: This retrospective cohort study compared results
using least squares (LS) multivariate regression with results from IV methods
that accounted for additional unmeasured patient characteristics. Primary
outcomes were 30-day and one-year mortality, and secondary outcomes included
treatment with medications and revascularization procedures.
DATA COLLECTION/EXTRACTION METHODS: Medical charts for the
initial hospital stay of each AMI patient underwent a comprehensive
abstraction, including dates of hospitalization, admitting physician,
demographic characteristics, comorbid conditions, severity of clinical
presentation, electrocardiographic and other diagnostic test results,
contraindications to therapy, and treatments before and after AMI.
PRINCIPAL FINDINGS: Patients admitted by cardiologists had
fewer comorbid conditions and less severe AMIs. These patients had a 10 percent
(95 percent CI: 9.5-10.8 percent) lower absolute mortality rate at one year.
After multivariate adjustment with LS regression, the adjusted mortality
difference was 2 percent (95 percent CI: 1.4-2.6 percent). Using IV methods to
provide additional adjustment for unmeasured differences in risk, we found an
even smaller, statistically insignificant association between physician
specialty and one-year mortality, relative risk (RR) 0.96 (0.88-1.04). Patients
admitted by a cardiologist were also significantly more likely to have a
cardiologist consultation within the first day of admission and during the
initial hospital stay, and also had a significantly larger share of their
physician bills for inpatient treatment from cardiologists. IV analysis of
treatments showed that patients treated by cardiologists were more likely to
undergo revascularization procedures and to receive thrombolytic therapy,
aspirin, and calcium channel-blockers, but less likely to receive
beta-blockers.
CONCLUSIONS: In a large population of elderly patients with
AMI, we found significant treatment differences but no significant incremental
mortality benefit associated with treatment by cardiologists.
View full story here. (Health Services
Research Journal)
Cardiac Revascularization in Specialty and General Hospitals
Peter Cram, M.D., M.B.A., Gary E. Rosenthal, M.D., and Mary S.
Vaughan-Sarrazin, Ph.D
ABSTRACT
Background:
The emergence of specialty hospitals focusing on narrow procedural
areas has generated controversy, although little is known about their quality.
Methods
We conducted a retrospective cohort study of 42,737 Medicare
beneficiaries who underwent percutaneous coronary intervention (PCI) and 26,274
who underwent coronary-artery bypass grafting (CABG) during 2000 and 2001 in
specialty cardiac hospitals (15 for PCI and 15 for CABG) and general hospitals
(82 for PCI and 75 for CABG) in the same markets. Administrative data were used
to compare patients' characteristics, hospital procedural volumes, and patient
outcomes.
Results
Patients undergoing PCI or CABG in specialty hospitals were less
likely to have coexisting conditions than those being treated at general
hospitals and were less likely to have had an acute myocardial infarction
(P<0.001). The better health of the patients at specialty hospitals than of
those at general hospitals was reflected by the lower mean predicted risk of
death (2.1 percent vs. 3.1 percent for PCI and 5.0 percent vs. 5.8 percent for
CABG; P<0.001 for each comparison). Mean volumes of PCI and CABG procedures
in 2000 and 2001 were higher in specialty hospitals than in general hospitals
(799 vs. 375 PCI procedures, P<0.001; and 571 vs. 236 CABG procedures,
P<0.001). The unadjusted rate of death during the index hospitalization or
within 30 days after admission was lower in specialty hospitals than in general
hospitals (2.1 percent vs. 3.2 percent for PCI and 4.7 percent vs. 6.0 percent
for CABG; P<0.001 for both comparisons). In multivariate analyses adjusted
for patients' characteristics, the odds ratio for death after PCI in specialty
hospitals and general hospitals was similar (0.89; 95 percent confidence
interval, 0.69 to 1.15; P=0.39), but the odds ratio for death after CABG was
lower in specialty hospitals than in general hospitals (0.84; 95 percent
confidence interval, 0.72 to 0.99; P=0.05). In stratified analyses comparing
specialty and general hospitals with similar volumes, differences in mortality
were not significant.
Conclusions
The lower unadjusted mortality rate after cardiac revascularization in
specialty cardiac hospitals is accounted for by their healthier patients and
higher procedural volumes.
View full story here. (New England Journal of Medicine)
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