Biomedical subjects
I S Nash
Publications and source records attributed to I S Nash.
Ethnic differences in the ST segment of the electrocardiogram: a comparative study among six ethnic groups.
Deviation of the ST segment of the electrocardiogram (ECG) may signify infarction or ischemia. Prior studies suggest that normal ECG patterns may differ among ethnic groups. We retrospectively reviewed the first thousand medical files of a multiethnic community, where all individuals shared similar living conditions. Only healthy adults, aged 15 to 60 years, were included. Along with age, the most common causes for exclusion were diabetes, hypertension, and ischemic heart disease. A total of 597 subjects (349 men) were included: 350 Saudi Arabians, 39 Filipinos, 95 Indians, 17 Sri-Lankans, and 57 Caucasians. Twenty men and one woman had an ECG pattern of early repolarization (ST segment elevation with upward concavity, notching on QRS, and large symmetrical T wave), with no difference in incidence among ethnic groups. ST segment elevation (2 mm in any of the leads V1-V4, or 1 mm in any of the other leads) without criteria of early repolarization occurred in 11.58%, 13.46%, 3.57%, 4.35%, 11.76%, 7.32% of Saudi, Indian, Jordanian, Filipino, Sri-Lankan, and Caucasian men, respectively (P =.61). Only one Jordanian and 2 Indian women had this pattern. However, Filipino men had higher median ST segment levels than others in leads V1 and V3. Among women, the median ST segment level was iso-electric in all leads in all ethnic groups. Only 3 subjects had ST segment depression >1 mm. Significant ST segment elevation is common in normal healthy men but may not fulfill criteria for early repolarization; it has no ethnic predilection. ST segment elevation is uncommon in normal women. ST segment depression is a rare finding in healthy adults regardless of ethnic origin.
Ethnic differences in electrocardiographic intervals and axes.
The presence of ethnic differences in electrocardiographic (ECG) patterns is debated. We retrospectively examined the first 1,000 medical files of a multi-ethnic community, where all individuals shared similar living conditions. Only healthy adults (ages 15 to 60 years) were included. All patients had similar socioeconomic, nutritional, environmental, and occupational conditions. Interval and axes measurements were obtained through integrated computerized analysis from a standard 12-lead ECG. ECGs from 597 patients were included in the study: 350 Saudi Arabians, 95 Indians, 39 Jordanians, 17 Sri-Lankans, 39 Filipinos, and 57 Caucasians; 349 patients were men. Interval and axes were compared by analysis of variance. No statistically significant differences were found among ethnic groups in PR interval, QRS duration, QT interval, P wave axis, QRS axis, or T wave axis in men (P =.05). In women, Jordanians had longer QRS duration than Filipinos (87.69 +/- 10.4, 78.81 +/- 5.47 ms, respectively, P =.014). P-wave axis was lower in Filipino women than Saudi, Indian, and Caucasian women (36.87 +/- 26.32, 50.39 +/- 16.88, 52.23 +/- 16.67, 63.19 +/- 14.55 degrees, respectively, P =.002). QRS axis was significantly higher in Filipino than Saudi women (53.06 +/- 26.14, 32.62 +/- 28.31 degrees, respectively, P <.014). There was no ethnic difference in ECG interval measurements in men. However, in women, there were differences in QRS interval, and P and QRS wave axes. Although women had a statistically significant difference in intervals, the magnitude was not clinically significant. Current reference standards for ECG intervals and axes can be used across the ethnic groups studied.
Generalist versus specialist care for acute myocardial infarction.
Early studies conflict regarding improved patient outcomes with cardiologist-directed care for acute myocardial infarction (AMI). We sought to assess the magnitude and mechanism of the influence of physician specialty on inpatient mortality for AMI. Using data from the Pennsylvania Health Care Cost Containment Council and elsewhere, we developed age-stratified logistic regression models of inpatient mortality, utilizing a split sample strategy for model development and validation. Referral bias and physician caseload were explicitly addressed. We analyzed 30,351 admissions for AMI. In patients < 65 years old, the adjusted odds ratio (OR) for mortality with cardiologist care was 0.89 (95% confidence interval [CI] 0.640 to 1.24, p = 0.49) relative to generalist care. In patients > or = 65 years of age, the adjusted OR was 0.86 (95% CI 0.72 to 1.03, p = 0.10). Caseload was significantly higher among cardiologists and was inversely related to inpatient mortality. Mortality models with caseload but not physician designation or physician designation without caseload found each predictor statistically significant in the absence of the other (OR for cardiologist care 0.82, 95% CI 0.71 to 0.95, p = 0.007; OR for patients with low volume physicians relative to high volume 1.27, 95% CI 1.05 to 1.51, p = 0.014). Older patients of physicians with higher case loads had a lower risk adjusted inpatient mortality for AMI. This probably explains the trend toward better outcomes among patients of cardiologists rather than noncardiologists.
Predictors of patient-reported physical and mental health 6 months after percutaneous coronary revascularization.
BACKGROUND: There is interest in measuring and comparing outcomes of percutaneous transluminal coronary angioplasty (PTCA) other than death, but there are no accepted methods for adjusting these outcomes for preprocedure differences in populations. We sought to identify independent predictors of functional outcome after PTCA. METHODS AND RESULTS: We developed multivariate risk adjustment models for the 6-month postprocedure physical and mental health summary scores of the MOS SF-36. Complete data were available on 1182 patients undergoing PTCA at 12 institutions. The mean physical component score (PCS) of the SF-36 rose from 36.6 before PTCA to 43. 4 at 6 months after PTCA (P <.0001). Independent predictors of follow-up PCS were baseline PCS, a composite index of comorbidities, prior coronary bypass surgery, baseline MOS SF-36 mental component score (MCS), age, and recent thrombolysis. The model had an adjusted R(2) value of 0.357. The mean MCS rose from 48.5 before PTCA to 50.5 at 6 months after PTCA (P <.0001). Independent predictors of postprocedure mental health were baseline MCS, age, and heart failure. The predictive model for MCS had an adjusted R(2) value of 0.235. CONCLUSIONS: Preprocedure patient-reported functional status and select clinical variables are significantly associated with physical functioning and mental health 6 months after PTCA. The predictive power of these models, however, is probably insufficient to allow their use for comparisons among institutions or providers.
Improving outcomes of percutaneous coronary intervention.
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Effectiveness of a computer-based system to teach bedside cardiology.
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The generalist/cardiovascular specialist: a proposal for a new training track.
The economic forces that are reshaping the delivery of health care in the United States have led to intense examination of the appropriate roles for specialists and generalists. Resolving this issue has profound implications for the future of U.S. health care and for the economic health of academic training centers and individual physicians. The issues are particularly intense in cardiovascular care, a field that has had dramatic success in the application of new diagnostic and therapeutic technology and rapid growth in specialist practitioners but is now under pressure to shrink its ranks. A new generalist/cardiovascular specialist training track and a parallel reduction in the number of standard fellowship training positions in cardiovascular disease may be a partial solution. The first 2 years of the proposed 5-year program would consist of training in internal medicine, the final 2 would consist of training in cardiovascular disease, and the middle year would be a flexible combination of the two. Graduates would be Board eligible in internal medicine but would have enhanced competency in cardiovascular disease. This plan may improve the balance between generalists and specialists, improve the quality of primary and specialized cardiovascular care, and strengthen departments of medicine and academic training centers while facing new economic realities.
Building the best team.
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Do cardiologists do it better?
Pressure to lower the cost of health care delivery has fostered widespread efforts to limit patients' access to specialists such as cardiologists. However, there is concern that diminished specialist involvement may lead to poorer patient outcomes for specific clinical conditions. As part of a state-sponsored effort to improve the quality of health care in Pennsylvania, the Pennsylvania Health Care Cost Containment Council gathered clinical and administrative data on all 40,684 hospital admissions for acute myocardial infarction (AMI) in that state in 1993. They prepared a detailed public report that included risk-adjusted in-hospital mortality and length of hospital stay by physician group, by hospital and by region. These data demonstrate that patients cared for by cardiologists, as a group, had a lower risk-adjusted mortality than patients cared for by either internists (risk ratio 1.26, 95% confidence interval 1.17 to 1.35) or family practitioners (risk ratio 1.29, 95% confidence interval 1.18 to 1.40). The patients of cardiologists also had a shorter length of stay than the other two groups. These data suggest that there is enhanced value in the care provided by cardiologists for patients with AMI and call into question the growing trend toward reliance on generalists instead of specialists.
Using quality and cost for employee incentives in a reengineered hospital setting.
The Mount Sinai Hospital is reengineering its inpatient services to increase the quality of patient care and achieve greater operational efficiency. The central component of this redesign has been the establishment of "care centers," which are administratively and fiscally separate "hospitals within the hospital." To promote quality and financial goals set for each care center, a novel employee incentive compensation program was created. Performance on both quality and financial indicators determines the level of bonus payments to hourly employees. The incentive compensation plan was initiated in the first quarter of 1996. By achieving two of the three performance targets, employees earned a bonus of 6% of base salary for the first two quarters. Nurses and pharmacists did not accept bonus payments because of collective bargaining agreements. The early experience of the Cardiac Care Center has been highly favorable. Changes are planned to improve the process further.
Measurement of intracardiac pressures.
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Physician, educate thyself.
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