Understanding racial differences in the use of thrombolytic therapy: what more do we need to know?
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Black or African American↗
Biomedical subjects
C Maynard
Publications and source records attributed to C Maynard.
A comparison of percutaneous transluminal coronary angioplasty in the Department of Veterans Affairs and in the private sector in the State of Washington.
Coronary angioplasty is performed > 1,000 times daily in a variety of health care settings in the public and private sectors in the USA. How outcomes for this procedure differ in the Department of Veterans Affairs and the private sector is unknown. The purpose of this study was to compare outcomes of coronary angioplasty performed in hospitals in the Department of Veterans Affairs and the State of Washington. This study used administrative data from the Department of Veterans Affairs patient treatment file (n = 8,326) and the State of Washington episode of illness file (n = 6,666) and included men who underwent coronary angioplasty in 1993 and 1994. Outcomes included (1) in-hospital mortality and mortality at 10 and 30 days after hospital admission, and (2) the use of coronary artery bypass surgery at similar intervals. Patients with a principal diagnosis of acute myocardial infarction were analyzed separately. Men in the Department of Veterans Affairs had more comorbid conditions than their counterparts in Washington State, and the length of hospital stay was longer in the former group. After using logistic regression to adjust for patient differences, mortality rates for the 2 groups of patients with acute myocardial infarction were similar, although bypass surgery was used more frequently in patients in Washington State. For patients without myocardial infarction, hospital and 10-day mortality did not differ with respect to health care system, and the use of bypass surgery subsequent to angioplasty was similar. In the Department of Veterans Affairs, most hospitals had low institutional caseloads (< 150 procedures per year), whereas > 40% of Washington State hospitals performed > or = 300 procedures per year. Although there were greatly differing institutional caseloads, mortality and the need for early bypass surgery were similar in the 2 systems.
Adult↗
Coronary angioplasty outcomes in the Healthcare Cost and Utilization Project, 1993-1994.
It is estimated that >400,000 percutaneous transluminal coronary angioplasty (PTCA) procedures are performed in the Unites States annually. This study reports patient characteristics and outcomes for 163,527 PTCAs performed in 214 hospitals in 17 states from 1993 to 1994. These hospitals were a 20% random sample of hospitals in the Healthcare Cost and Utilization Project, which was designed to reflect hospitalization in the United States, generally. Cases with International Classification of Diseases, 9th Revision, Clinical Modification procedure codes 36.01, 36.02, and 36.05 were defined as PTCA and were categorized as to whether acute myocardial infarction (AMI) was the principal discharge diagnosis. The average age of 44,270 AMI discharges (27%) was 62 +/- 12 years and that of 119,257 no-AMI cases (73%) was 64 +/- 11 years; 1/3 of both groups were women, 88% were white, and almost 90% had Medicare or private insurance as the primary payer. The states contributing the most cases were Florida (26%), California (12%), and Wisconsin (10%). Hospital mortality was 1.7% overall and was 3.8% for AMI and 0.8% for no-AMI cases. Bypass surgery performed during the same admission was 3.4% overall and was 4.5% and 3.0% for AMI and no-AMI cases, respectively. Multivariate analysis showed that advanced age, diabetes, female gender, and Medicaid payer status were associated with increased risk of mortality. National estimates from this 20% sample indicate that >850,000 PTCAs were performed in the 2 years, with 452,319 cases estimated for 1994. In 1994 there were an estimated 2,789 deaths and 9,903 bypass surgeries in the no-AMI subset of 327,856 procedures. For the AMI group of 124,463 procedures, there were 4,486 deaths and 5,799 bypass surgeries in 1994. This study of PTCA outcomes contains the largest number of cases as well as the most representative sample reported to date.
Angioplasty, Balloon, Coronary↗
Primary care physician compensation method in medical groups: does it influence the use and cost of health services for enrollees in managed care organizations?
CONTEXT: Growth of at-risk managed care contracts between health plans and medical groups has been well documented, but less is known about the nature of financial incentives within those medical groups or their effects on health care utilization. OBJECTIVE: To test whether utilization and cost of health services per enrollee were influenced independently by the compensation method of the enrollee's primary care physician. DESIGN: Survey of medical groups contracting with selected managed care health plans, linked to 1994 plan enrollment and utilization data for adult enrollees. SETTING: Medical groups, major managed care health plans, and their patients/enrollees in the state of Washington. STUDY PARTICIPANTS: Sixty medical groups in Washington, 865 primary care physicians (internal medicine, pediatrics, family practice, or general practice) from those groups and affiliated with 1 or more of 4 managed care health plans, and 200 931 adult plan enrollees. INTERVENTION: The effect of method of primary care physician's compensation on the utilization and cost of health services was analyzed by weighted least squares and random effects regression. MAIN OUTCOME MEASURES: Total visits, hospital days, and per member per year estimated costs. RESULTS: Compensation method was not significantly (P>.30) related to utilization and cost in any multivariate analyses. Patient age (P<.001), female gender (P<.001), and plan benefit level (P<.001) were significantly positively related to visits, hospital days, and per member per year costs. The primary care physician's age was significantly negatively related (P<.001) to all 3 dependent measures. CONCLUSIONS: Compensation method was not significantly related to use and cost of health services per person. Enrollee, physician, and health plan benefit factors were the prime determinants of utilization and cost of health services.
Capitation Fee↗
Randomized, controlled trial of RheothRx (poloxamer 188) in patients with suspected acute myocardial infarction. RheothRx in Myocardial Infarction Study Group.
BACKGROUND: Patients with acute myocardial infarction (AMI) who are not eligible for thrombolytic therapy or primary coronary angioplasty are distinguished by advanced age, complicated medical histories, relatively frequent use of prior revascularization procedures, and worse outcomes than their counterparts who are eligible for reperfusion therapy. METHODS AND RESULTS: The purpose of this randomized, controlled trial was to determine whether RheothRx, a hemorheologic agent, reduced myocardial infarct size and improved left ventricular function in patients who had suspected AMI at the time of hospital admission and were not eligible for reperfusion therapy. Patients were randomly assigned to RheothRx (n = 97) or placebo (n = 99). Patients in the two groups were similar with respect to age, sex, medical history, and clinical presentation. Enzyme evidence of AMI was present in 69% of the treatment group and 70% of the placebo group. Infarct size measured before hospital discharge was similar in the two groups (14.1% +/- 18.5% vs 11.7% +/- 14.1%, p = 0.60), although left ventricular ejection fraction was lower in the treatment group (47 +/- 14 vs 52 +/- 11, p = 0.026). Hospital mortality rate was 11.3% and 7.1% in patients receiving RheothRx and patients receiving placebo, respectively (p = 0.30). There was a higher occurrence of acute renal dysfunction in the RheothRx group (12% vs 2%, p = 0.005). Because of changes in drug dosage necessitated by the occurrence of acute renal dysfunction, the trial was stopped. CONCLUSIONS: In this study of patients who had suspected AMI and were not eligible for thrombolytic therapy, RheothRx did not decrease infarct size or favorably alter outcome. The need for effective treatment for this large patient population remains largely unmet.
Acute Kidney Injury↗
Evaluating treatment for intractable angina pectoris: a challenging clinical and scientific problem.
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Angina Pectoris↗
Utility of the prehospital electrocardiogram in diagnosing acute coronary syndromes: the Myocardial Infarction Triage and Intervention (MITI) Project.
OBJECTIVES: We sought to determine whether the prehospital electrocardiogram (ECG) improves the diagnosis of an acute coronary syndrome. BACKGROUND: The ECG is the most widely used screening test for evaluating patients with chest pain. METHODS: Prehospital and in-hospital ECGs were obtained in 3,027 consecutive patients with symptoms of suspected acute myocardial infarction, 362 of whom were randomized to prehospital versus hospital thrombolysis and 2,665 of whom did not participate in the randomized trial. Prehospital and hospital records were abstracted for clinical characteristics and diagnostic outcome. RESULTS: ST segment and T and Q wave abnormalities suggestive of myocardial ischemia or infarction were more common on both the prehospital and hospital ECGs of patients with as compared with those without acute coronary syndromes (p < or = 0.00001). Those with prehospital thrombolysis were more likely to show resolution of ST segment elevation by the time of hospital admission (14% vs. 5% in patients treated in the hospital, p = 0.004). In patients not considered for prehospital thrombolysis, both persistent and transient ST segment and T or Q wave abnormalities discriminated those with from those without acute coronary ischemia or infarction. Compared with ST segment elevation on a single ECG, added consideration of dynamic changes in ST segment elevation between serial ECGs improved the sensitivity for an acute coronary syndrome from 34% to 46% and reduced specificity from 96% to 93% (both p < 0.00004). Overall, compared with abnormalities observed on a single ECG, consideration of serial evolution in ST segment, T or Q wave or left bundle branch block (LBBB) abnormalities between the prehospital and initial hospital ECG improved the diagnostic sensitivity for an acute coronary syndrome from 80% to 87%, with a fall in specificity from 60% to 50% (both p < 0.000006). CONCLUSIONS: ECG abnormalities are an early manifestation of acute coronary syndromes and can be identified by the prehospital ECG. Compared with a single ECG, the additional effect of evolving ST segment, T or Q waves or LBBB between serially obtained prehospital and hospital ECGs enhanced the diagnosis of acute coronary syndromes, but with a fall in specificity.
Bundle-Branch Block↗
Use of angiotensin-converting enzyme inhibitors at discharge in patients with acute myocardial infarction in the United States: data from the National Registry of Myocardial Infarction 2.
OBJECTIVES: This study was undertaken to examine recent trends in the use of angiotensin-converting enzyme (ACE) inhibitor therapy in patients discharged after acute myocardial infarction (AMI) and to identify clinical factors associated with ACE inhibitor prescribing patterns. BACKGROUND: Clinical trials have demonstrated a significant mortality benefit in patients treated with ACE inhibitors after AMI. Numerous studies have demonstrated underuse of other beneficial treatments for patients with AMI, such as beta-adrenergic blocking agents, aspirin and immediate reperfusion therapy. METHODS: Demographic, procedural and discharge medication data from 190,015 patients with AMI were collected at 1,470 U.S. hospitals participating in the National Registry of Myocardial Infarction 2. RESULTS: Prescriptions for ACE inhibitor therapy at hospital discharge increased from 25.0% in 1994 to 30.7% in 1996. Patients with a left ventricular ejection fraction < or =40% or evidence of congestive heart failure while in the hospital were discharged with ACE inhibitor treatment 42.6% of the time. Of patients experiencing an anterior wall myocardial infarction and no evidence of heart failure, 26.1% of patients were discharged with this treatment. Of the remaining patients, 15.6% received ACE inhibitors at discharge. ACE inhibitors were prescribed more often to elderly and diabetic patients as well as those requiring intraaortic balloon pump placement. This therapy was given less often to patients who underwent revascularization with coronary angioplasty or coronary artery bypass graft surgery or were treated with calcium channel blocking agents. CONCLUSIONS: Physicians are prescribing ACE inhibitors in patients with myocardial infarction with increasing frequency. Those patients with the greatest expected benefit receive ACE inhibitor treatment most often. However, the majority of even these high risk patients were not discharged with this life-saving therapy.
Adrenergic beta-Antagonists↗
Specificity of electrocardiographic myocardial infarction screening criteria in patients with nonischemic cardiomyopathies.
BACKGROUND: The 32-point, 54-criteria Selvester QRS scoring system has been successfully used to estimate the size of nonacute myocardial infarction (MI). Three criteria of the system have been shown to be sensitive for the identification of nonacute MI and specific in normal control subjects. The validity of the system has not been tested in patients with cardiomyopathy of nonischemic origin. The purpose of this study was to examine the electrocardiographs (ECGs) of patients with abnormal left ventricular function but no presence of coronary disease to determine the diagnostic specificity of the MI screening criteria subset of the Selvester QRS scoring system. METHODS AND RESULTS: Six hundred ninety patients were considered. Exclusion criteria included age <10 years, cardiac transplantation, thrombolytic therapy, any angiographic evidence of coronary disease, left ventricular ejection fraction (LVEF) >60%, or history of myocardial revascularization. ECG exclusion criteria included left ventricular hypertrophy, right ventricular hypertrophy, left bundle branch block, right bundle branch block, ventricular pacing, left anterior fascicular block, left posterior fascicular block, ventricular preexcitation, and low voltage, because these confounding factors could mimic an infarct on the ECG. The 261 remaining patients were then examined for the presence of the MI screening criteria subset: (1) inferior location: Q > or =30 msec in aVF, (2) anterior location: either any Q or R< or =0.1 mV and < or =10 msec in V2, and (3) posterior location: R> or =40 msec in V1. Thirty-two of the 261 patients falsely met at least 1 of the 3 MI screening criteria, resulting in an overall specificity of 88% (vs 95% in normal control subjects, P=.0006). A specificity of 98% (n = 256) was achieved for the inferior MI screening criterion alone, whereas the anterior and posterior MI screening criteria alone achieved significantly lower specificities: 94% (n = 245) and 95% (n = 249), respectively. When the patient population was divided into LVEF <30% and LVEF > or =30%, no significant association was found between MI screening criteria and LVEF with specificities of 87% and 88%, respectively, for the 2 groups (P= .34). CONCLUSIONS: The MI screening criteria subset is relatively specific in patients with nonischemic cardiomyopathy, falsely identifying only 12% with nonacute MI. However, this specificity is lower than the 95% achieved in normal subjects. Regional accumulation of scarring caused by cardiomyopathy could result in false-positive indication of MI in the present population. Another possibility could be that some patients could have hypertrophy of the myocardium insufficient to produce positive ECG criteria for left ventricular hypertrophy or right ventricular hypertrophy but sufficient to mimic infarction.
Adult↗
Psychiatric hospitalization of persons with dual diagnoses: estimates from two national surveys.
Individuals with both mental illness and alcohol or drug use disorders present distinctive treatment and human service problems, including increased risk for psychiatric hospitalization in community hospitals. Using national hospital discharge abstract data for 1990 and 1994, this study compared differences in psychiatric hospitalization in community hospitals of patients with mental illness only and those with mental disorders and substance use disorders. Individuals with dual diagnoses were younger, and a greater proportion were men. Medicaid was the primary payer for a larger percentage of those with dual diagnoses. Nationally, the number of community hospitalizations for dually diagnosed patients increased 15 percent from 1990 to 1994, and total hospital charges increased from $1.9 to $2.2 billion.
Adult↗
Inter-regulated balance between gelatinases and tissue inhibitor (TIMP-1) in isolated human glomeruli.
Leukocyte infiltration inside glomeruli necessitates basement membrane collagen i.v. breakdown and leads to mesangiolysis, cell proliferation and extracellular matrix synthesis during the repair process as observed in the course of acute glomerulonephritis, vasculitis and acute graft rejection. Two matrix metalloproteinases, MMP-2 and MMP-9 gelatinases, are expressed and co-secreted in balance with the tissue inhibitor of metalloproteinases-1 (TIMP-1) by activated neutrophils as well as by glomerular cells and are aimed to control basement membrane collage i.v. deposition. Using a conventional double mesh sieving method, pure populations of glomeruli were isolated from fresh human cortex specimen and maintained in short-term cultures. ELISA, zymography and immunoblotting of conditioned serum-free media revealed glomerular MMP-2, MMP-9 and TIMP-1 secretion and activity while reverse transcription-polymerase chain reaction amplification of cellular RNA demonstrated glomerular transcripts coding for these enzymes and their inhibitor. When purified neutrophils were allowed to adhere onto Transwell apparatus in contact with glomerular suspensions, neutrophil 92 kDa gelatinase seemed apparently inhibited mainly because the production of TIMP-1 was enhanced on both sides of the insert. Glomerular 72 kDa and 92 kDa gelatinases were activated shortly (1 to 6 h) after neutrophils had interacted with glomeruli and furthermore upon activation by inflammatory or vasoactive mediators such as phorbol. Decreased neutrophil MMP-9 activity together with reduced MMP-9 mRNA levels and protracted TIMP-1 transcription and secretion during cell-cell interaction could participate to cell detachment from degraded basement membranes and to increased collagen i.v. deposition leading to glomerulosclerosis after initial glomerular injury by inflammatory cells.
Cells, Cultured↗
Patient-specific predictions of outcomes in myocardial infarction for real-time emergency use: a thrombolytic predictive instrument.
BACKGROUND: Thrombolytic therapy can be life-saving in patients with acute myocardial infarction. However, if given too late or insufficiently selectively, it may provide little benefit but still cause serious complications and incur substantial costs. OBJECTIVE: To develop a thrombolytic predictive instrument for real-time use in emergency medical service settings that could 1) identify patients likely to benefit from thrombolysis and 2) facilitate the earliest possible use of this therapy. DESIGN: Creation and validation of logistic regression-based predictive instruments based on secondary analysis of clinical data. PATIENTS: 4911 patients who had acute myocardial infarction and ST-segment elevation on electrocardiogram; 3483 received thrombolytic therapy. MEASUREMENTS: Data were obtained from 13 major clinical trials and registries and directly from medical records, including electrocardiograms obtained at presentation. Input variables include presenting clinical and electrocardiography features; predictive models generate probabilities for acute (30-day) mortality if and if not treated with thrombolysis, 1-year mortality rates if and if not treated with thrombolysis, cardiac arrest if and if not treated with thrombolysis, thrombolysis-related intracranial hemorrhage, and thrombolysis-related major bleeding episode requiring transfusion. Together, these models constitute the thrombolytic predictive instrument. RESULTS: The predictive models generated the following mean predictions for patients in the Thrombolytic Predictive instrument Database: 30-day mortality rate, 7.1%; 1-year mortality rate, 10.9%; rate of cardiac arrest, 3.7%; rate of thrombolysis-related intracranial hemorrhage. 0.6%; and rate of other thrombolysis-related major bleeding episodes, 5.0%. They discriminated with between persons having and those not having the predicted outcome; areas under the receiver-operating characteristic (ROC) curve were between 0.77 and 0.84 for the five outcomes. Calibration between each instrument's predicted and observed served rates was excellent. Validation of the predictive instruments of 30-day and 1-year mortality, done on a separate test dataset, yielded areas under the ROC curve of 0.76 for each CONCLUSIONS: After the basic features of a clinical presentation are entered into a computerized electrocardiograph, the predictions of the thrombolytic predictive instrument can be printed on the electrocardiogram report. This decision aid may facilitate earlier and more appropriate use of thrombolytic therapy in patients with acute myocardial infarction.
Cerebral Hemorrhage↗
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.
Aged↗
Factors associated with rehospitalization in patients with acute myocardial infarction.
Rehospitalization of patients surviving acute myocardial infarction is common, but why it occurs is not well documented. In Seattle area hospitals, rehospitalization was frequent, particularly for women and those with extensive cardiac histories.
Aged↗
Association of gender and survival in patients with acute myocardial infarction.
BACKGROUND: During the last 5 years, many studies have produced conflicting results concerning the survival of women hospitalized with acute myocardial infarction (AMI). OBJECTIVE: To determine if gender is associated with hospital mortality and long-term survival in individuals with AMI. METHODS: This prospective study included 4255 consecutive women (34%) and 8076 (66%) men who developed AMI in 19 Seattle, Wash, area hospitals between January 1988 and June 1994. Key information was abstracted from hospital records and entered in the Myocardial Infarction Triage and Intervention registry database. In addition, data concerning survival and rehospitalization were obtained from the state of Washington and linked to the Myocardial Infarction Triage and Intervention registry. RESULTS: In comparison with men, women were 8 years older, more often had history of congestive heart failure, hypertension, or diabetes mellitus, and less often had history of myocardial infarction or coronary surgery. During hospitalization, women were less likely to undergo coronary angiography, thrombolytic therapy, coronary angioplasty, or bypass surgery. After adjustment for covariates, women were 20% more likely to die in the hospital (odds ratio, 1.22; 95% confidence interval, 1.06-1.39), yet long-term survival was similar in the 2 groups (hazard ratio, 0.97; 95% confidence interval, 0.90-1.05). The use of thrombolytic therapy or revascularization during the index hospitalization did not change the association between gender and survival. CONCLUSIONS: All things being equal, women with AMI were more likely to die in the hospital, yet survival after hospital discharge did not differ according to gender. Appropriate treatment to reduce hospital mortality in women is needed.
Aged↗
[Mesenteric ischemia in hemodialyzed patients].
OBJECTIVES: Mesenteric ischemia is uncommon in the general population but is frequently encountered in chronic hemodialysis patients. We present here four cases which occurred in our unit within one year while only six cases had been observed in the preceding twenty years. OBSERVATIONS: Four chronic hemodialysis patients (age: 57 to 76 years) with renal failure due to diffuse atheromatous disease, presented non-occlusive mesenteric ischemia. One patient died and one underwent resection of the colon. For the final two patients, prophylactic therapy was initiated. DISCUSSION: Mesenteric ischemia is a severe condition which appears to occur more frequently in end-stage renal disease. In the chronic hemodialysis patient excessive ultrafiltration or a too rapid filtration rate can favor ischemia. Prophylactic measures must be taken at the first sign of ischemia, especially since clinical and biological features of mesenteric ischemia remain largely non-specific.
Aged↗
Racial differences in the utilization of public mental health services in Washington State.
This study analyzed racial differences in the use of public outpatient mental health services in four regions of Washington State. Patients in this study were enrolled in the state's mental health management information system, which contains detailed information about patient characteristics and service utilization. There were distinct racial differences with respect to baseline characteristics, and even after adjusting for these characteristics and region of the state as well, racial differences in the type and amount of services used persisted. In particular, African-Americans were more likely to use crisis services and were less likely to use individual or group treatment. This previously reported finding requires further exploration.
Adolescent↗
Comparison of teaching the basic electrocardiographic concept of frontal plane QRS axis using the classical versus the orderly electrocardiogram limb lead displays.
This study compares the effectiveness of teaching the calculation of frontal plane QRS axis with the use of the classical versus the orderly electrocardiographic limb lead display. Eighty-three students from two environments were randomized into two groups and were taught to determine frontal plane axis with one of the methods. The accuracy and time to determine the axis were tested on 10 electrocardiograms. In the United States the group using the classical display achieved 4.2 (+/-2.7) correct answers, whereas those using the orderly method achieved 6.8 (+/-3.0) (p = 0.0006). The classical group used 9.2 (+/-2.8) minutes to complete the test, whereas the orderly group needed 7.2 (+/-2.0) minutes (p = 0.015). The results achieved in Sweden were similar. The use of the orderly electrocardiographic limb lead display results in greater diagnostic accuracy in less time than the classical display when determining the frontal plane QRS axis.
Adult↗